228

Imperial Journal of Interdisciplinary Research (IJIR)
Vol-2, Issue-9, 2016
ISSN: 2454-1362, http://www.onlinejournal.in
Imperial Journal of Interdisciplinary Research (IJIR) Page 1444
Prevalence Of Trachoma And Associated Factors Of Children
Aged 1-9 Years In Community Led Total Sanitation And
Hygiene Triggered Village And None Triggered In Girar Jarso
Woreda, North Shoa, Oromia, Ethiopia.
Thomas Ayalew
(BSC, MPH)) Department of WASH, International Medical Corps, Shashamane, Ethiopia,
Abstract
Background: - Trachoma is the leading cause of
infectious blindness worldwide. Problem with
trachoma can be prevented through Sanitation and
Hygiene improvement. This study assesses the
relation between triggering villages through
CLTSH and significant result on blinding
trachoma.
Objective: Assessment of Trachoma prevalence and
associated factors among in CLTSH triggered
village and non-triggered village of Girar Jarso
Woreda, North Shoa, Oromia Region, Ethiopia,
2014.
Methods: A comparative cross-sectional study was
done in CLTSH triggered village and non-triggered
village of Girar Jarso Woreda, North Shoa,
Oromia Region, Ethiopia. The sample size
determined using the formula of sample size
determination for two population proportion.
Based on stat calc of EPI info 3.5.1.0.for cross
sectional study designs, the actual sample size
calculated to be 644(322 from each group)
children aged 1-9years. A multi-stage sampling
technique was employed. A Structured
questionnaire and WHO guideline for Trachoma
Assessment also used. Data was managed and
analyzed by SPSS version 20.
Result: -. From the total children assessed, active
trachoma was found to be 179(27.8%). It was also
observed from this study that 22 (3.4%) had
trichiasis and 15(2.3%) were observed to have
corneal opacity. The prevalence of trachoma in the
two comparison group had no significant
difference and children in the community led total
sanitation and hygiene triggered village had no
lower risk of trachoma. Variables such as open
defecation free, any piles of animal dung or
rubbish lying in open place, frequency of washing
hands and faces, type of detergent they use, main
source of water were associated with trachoma
reduction (P-values <0.05 ) in multivariate
analysis.
Conclusion: - The prevalence of trachoma in the
two comparison group had no significant
difference, rather encouraging reduction of
trachoma in Open defecation free villages.
Keywords: Community led Total sanitation and
Hygiene (CLTSH), Open defecation free,
Triggering (CLTSH), Trachoma
Background
Blindness due to trachoma is irreversible once it
has occurred, but it can be prevented. The SAFE
strategy (Surgery for trichiasis, Antibiotics to treat
Chlamydia trachomatis infection, and Facial
cleanliness and Environmental improvement to
reduce transmission of Chlamydia trachomatis
from one person to another) is recommended for
the control of trachoma. With the SAFE strategy,
the World Health Organization (WHO) and its
partners are targeting the Global Elimination of
Trachoma as a cause of blindness by the year 2020
(GET2020). GET2020 is one element of a broader
strategy known as ‘VISION 2020: The Right to
Sight’, which has as its goal the elimination of all
avoidable blindness by the same year (1).
Trachoma is an eye disease caused by poor
sanitation and hygiene. Flies spread the disease in
areas where people openly defecate. People can
easily prevent trachoma by washing their hands and
faces regularly. Latrine construction and use can
also prevent trachoma. Eliminating trachoma and
other diseases caused by lack of clean water,
sanitation and hygiene would improve people’s
well being, reduce the costs of curative health care
and help strengthen local economies (2).
Hygiene and sanitation promotion has been gaining
momentum in Ethiopia, where the number of
people with access to a latrine has been improving
(access reached 60 percent in 2011). However, the
use and management of available latrines remains
poor. Many international agencies and non-
governmental organizations have been working to
improve the hygiene and sanitation situation by
constructing latrines using various kinds of
subsidies. But even after such efforts, it remains

difficult to find a single village in the country that
is completely sanitized and free from open
defecation. Success has generally been measured
on the basis of the number of latrines constructed
within a given period of time instead of on the
extent to which people continue to practice open
defecation even when latrines are available (3).
There is only one species of fly, which is currently
proposed as the main vector for trachoma, the
Bazaar fly, Musca Sorbens. ‘The larval medium for
Musca sorbens faeces and it shows a marked
preference for human faeces over any other type
(4). It only uses human excreta available in the
environment: larval stages have not been found in
latrines and adults have not been caught emerging
from them (4, 5).
The effective use of latrines therefore provides a
break in the chain of fly breeding and its larval
stages. Hence if latrine use is community wide and
accepted and used by the men, women and children
concerned, and then it can provide effective barrier
to the spread of trachoma through the vector of the
fly (6).
Programmes improving community water supplies
can contribute to the overall Prevention of
trachoma. Sanitation can be promoted by the health
sector through a stand-alone programme such as
sanitation marketing or CLTSH (Community Led
Total Sanitation and Hygiene) (7).
The CLTSH approach originates from Kamal Kar’s
evaluation of Water Aid Bangladesh and their local
partner organization – VERC’s (Village Education
Resource Centre is a local NGO) traditional water
and sanitation programme and his subsequent work
in Bangladesh in late 1999 and into 2000. CLTSH
in Ethiopia have not been popular until now.
Moreover, the pace of change has been too slow to
achieve universal access within the stated time
frame (8).
Methods and materials
Study design and setting
A comparative cross-sectional study was conducted
from September 25, 2014 to March 21, 2015 in
Girar Jarso woreda, North Shoa, and Oromia
Region, Ethiopia. North Shoa Zone is divided into
fourteen administrative woreda. Girar Jarso woreda
is 110km from capital city of Ethiopia to North
90
47.823 and to East 380
43.938. According to 2014
CSA population projection the woreda’s total
population is 83,070. Which are 42,536 are male
and 40,534 are female. In addition, despite the
same average family size of six, it is less densely
populated (350/sq.km).The infrastructure situation
is also better: There are 46 Primary schools, 17
health post and 3 health center. In the woreda there
are seventeen rural kebeles and 439 villages. (2007
CSA and May, 2009 baseline survey executive
summary report of Girar Jarso woreda on WASH
status by UNICEF)
Sample size determination and sampling
procedures
To assess where a significant different between two
groups, the sample size was determined using the
formula of sample size determination for two
population proportion. Based on EPI info version
3.5.1 for cross sectional study designs, the actual
sample size was 644 (322 from each group).
To calculate the sample size the following
assumptions were used ; level of significance 95%
, power 80% , ratio of exposed to unexposed 1,
expected frequency of disease among unexposed
group 47.9%.(37) AND OR (2).
The calculated sample size was 292. With
adjustment for non response (10%) and design
effect of 2, the final sample size was 644.
A multi-stage sampling technique employed in
order to select the study units. The study unit was
children’s that are found in two group (CLTSH
triggered and non CLTSH triggered) zone of Girar
Jarso woreda. The study area is selected so as to
represent the woreda in terms of both CLTSH
triggered and non CLTSH triggered.
Data collection procedures and quality
assurance
The data was collected using a pre-tested and
structured questionnaire prepared to address all the
important variables. The questionnaire was first
prepared in English version, and then translated to
Oromiffa. The variables in the questionnaire were
adapted from previous studies and by consulting of
advisors and individuals. The 6 data collector and 1
supervisor was trained and standardized
particularly in the proper filling of questionnaire.
Trachoma assessment was done for each child by
trained 3 ophthalmic nurses. The ophthalmic nurses
were received refresher training on trachoma
grading in the form of lecture using standard slides
showing various grades of trachoma.
Standardization of eye examinations for trachoma
then have done in Girar Jarso woreda among in
CLTSH triggered village and non-triggered village
community settings. Each ophthalmic nurse

standardized against highly experienced
ophthalmologist in trachoma diagnosis (gold
standard).Trachoma grading has done using the
WHO grading system.
To improve the quality of the data, the data
collectors have been closely supervised, each
completed questionnaire was checked to ascertain
all questions were properly filled and corrected by
principal investigator. The information was
rechecked in a randomly selected sub sample (5%).
Data processing and analysis
Data was cleaned manually and then entered into
the computer using Epi-Info Version 3.5.1.0 and
statistical analysis made using SPSS version 20.0.
First, descriptive analyses were carried out to
explore the socio-demographic characteristics of
the respondents. Bivariate analyses were carried
out to examine the relationship between the
Outcome variables and selected determinant
factors. P value and 95%Confidence Interval be
also used as appropriate. Factors for which
significant association observed have been retained
for subsequent multivariate analyses using logistic
regression to control the possible confounding
effect and assess the separate effects of the
variables.
Ethical considerations
Ethical clearance obtained from Debramarkos
University and GAMBY College of Medical
Sciences. A written consent was sought from local
authorities and concerned government bodies.
Informed verbal consent has been received from
each families of study subject. Anyone who did
not take part in the study has been given the right to
withdraw from the study at any time.
Information on the studies has been given to the
participants, including purpose and procedures,
potential risk and benefits so encourage provision
of accurate and honest responses. Potential
participants have been told that participation was
voluntary and that confidential and private
information has been protected.
All study subjects who had trachoma during data
collection were linked to health center and
managed after the agreement was reached with
families of study subjects about the benefit of
linkage. The management was so simple because
there were health professionals trained from each
health center.
Results
Socio-demographic characteristics of study
participants
A total of 644 children aged 1 to 9 years
participated with response rate of 100% as well as
examined their eye’s for trachoma assessment in
the study. Three hundred twenty two (50%)
children from CLTSH triggered and 322(50%)
from CLTSH not triggered included in the study.
Of total study subjects 354(55%) were males and
290(45%) were females. The mean age of study
population was 5.49 +2.57(SD). Six hundred forty
four (100%) children were followers of Orthodox
Christianity. About 329(51.1%) of the children
were from large (>5) family members. As to
educational background of children’s mother, the
illiterate were 576(89.4%), primary (1-8 grades)
were 52(8.1%), secondary and above (9-12+
grades) were 16(2.5%). Six hundred three (93.6%)
children’s family occupation was farmer. About
188(29.2%) of the children were from families
whose monthly incomes less than 1455birr. (Table
1)
Table, 1: Socio-demographic characteristics of among children aged 1-9 years in CLTSH and non CLTSH
villages, Girar Jarso Woreda, North Shoa, Oromia Region, Ethiopia in 2015.
Characteristics Children aged 1-9 years in
triggered CLTSH
Children aged 1-9 years in
None triggered CLTSH
Number %(percent) Number %(percent)
Age
1-4 109 34 118 37
5-9 213 66 204 63

Sex
Male 175 54 179 56
Female 147 46 143 44
Religion
Orthodox 322 100 322 100
Climate Condition
Dega(2500m-3500m) 322 100 0 0
Kola(500m-1500m) 0 0 322 100
Maternal Educational Status
No education/0/ 260 81 316 98
Primary /1-8grade/ 46 14 6 2
Secondary and above/9-12+
grade/ 16 4.97 0 0.00
Family size
< 5 154 48 161 50
> 5 168 52 161 50
Average Annual family income
Low <1455birr/month 131 41 57 18
Middle/1455bir to 6380bir/month 182 57 265 82
High />6380birr/month 9 2.80 0 0.00
Water access and Hygiene practice
Eighty one percent of triggered village got water
from protected hand pump well while 74.53% of
none triggered village fetched from pond or “kure”.
Hand and face wash using soap and other substitute
ranged 57% for triggered CLTSH. (Table 2)
Table, 2: water access and Hygiene practice of children aged 1-9 years in CLTSH and non CLTSH villages,
Girar Jarso Woreda, North Shoa, Oromia Region, Ethiopia, 2015.
triggered CLTSH
Number %(percent) Number %(percent)
Main source of water
Protected spring 32 10 0 0
Protected well 260 81 0 0
Unprotected spring 30 9 40 12.42

River 0 0.00 42 13.05
Other “Kure" 0 0.00 240 74.53
Amount of water per day
Shortage(< 20litre/day/person) 230 71 161 50
Sufficient(>20litre/day/person) 92 29 161 50
Make the water safer to drink by
Nothing used 289 90 322 100
Boil 3 1 0 0
Strain through a cloth 30 9.32 0 0
Type of detergent they use
Only with water 140 43 322 100
Soap/Ashes 182 57 0 0
Frequency of washing your hand
Once a day 65 20 322 100
Twice a day 243 75 0 0
More than twice 11 3.42 0 0
Sometimes 3 0.93 0 0
Sanitation status
Eighty four percent of children from triggered
village had access to traditional latrine while 100%
of children from none triggered village no access to
any type of latrine. About 152(47%) from triggered
CLTSH were Open defecation free. (Table 3)
Table, 3: Sanitation status of children aged 1-9 years in CLTSH and non CLTSH villages, Girar Jarso Woreda,
North Shoa, Oromia Region, Ethiopia, 2015.
triggered CLTSH
Frequency
n=322
%(percent) Frequency
n=322
%(percent)
Any piles of animal dung/ Rubbish lying in
open place
No 187 58 0 0
Yes 135 41.93 322 100
Availability of standardize latrine
No 47 15 322 100

Yes 275 85.40 0 0
Type (options) of latrines
No type to use 47 15 322 100
Traditional pit Latrine 272 84.47 0 0
Improved pit Latrine 3 0.93 0 0
Utilize of latrine
No 54 17 322 100
Yes 268 83.23 0 0
Do Children
ODF
No 170 53 322 100
Yes 152 47 0 0
Children from triggered CLTSH had higher water sanitation and hygiene facility than Children from none
triggered CLTSH.
Fig.1 The disparity of children by triggered and not triggered CLTSH with selected characters tics, Girar Jarso
Woreda, 2015.

Prevalence of trachoma
From the total children assessed, 216(33.5%) had
all grade of trachoma (TF, TI, TT and CO) of
which 118(54.6%) were males and 98(45.4%) were
females. The number of children with active
trachoma (TF and TI) was found to be 179(27.8%).
It was also observed from this study that 22 (3.4%)
of the cases require lid surgery for trichiasis and
15(2.3%) were observed to have had corneal
opacity. There were no children (0%) who
developed signs of Trachomatous Scarring
(TS).The prevalence of trachoma in CLTSH
triggered village was 102(15.84%) and it was
114(17.7%) for CLTSH non triggered village.
(Table 4)
Table 4: Distribution of Children (examination results) by grades of trachoma Girar Jarso Woreda, North Shoa
Zone, Oromia, Ethiopia, 2015.
Grades of trachoma Frequency Percent
No 428 66.5
TF/TI 179 27.8
TS 0 0
TT 22 3.4
CO 15 2.3
All Grade(2+4+5) 216 33.54
Total 644 100.0
Factors Associated with trachoma
There was no significant association between the
prevalence rates of the CLTSH triggered areas and
not triggered areas with p value=0.99 means result
from logistic regression showed that there was no
significant difference between means of two
groups.
Contribution of other variables to occurrence of
trachoma was also assessed by using bivariate
analysis. Thus variables like, presence of flies,
children ODF, utilize of latrine, type (options) of
latrines, availability of standardize latrine, any piles
of animal dung/ rubbish lying in open place,
children home exposed to eye irritants, children
who had eyes/nasal discharge and discharge wiping
material, frequency of washing hands and faces,
type of detergent they use, amount of water per
day, average annual family income and main
source of water were found to be significantly
associated with trachoma (p-values were <0.05 for
each factor).
In multivariate level of analysis; children from
family low monthly income
(<1455bir/month/family) were 3 times more likely
to have trachoma than middle average income
(1455 to 6380bir/month/family) of their counter
parts, (AOR=3.00, 95%CI=1.76-5.14, p-value
<0.001). (Table 5)
Table 5: Prevalence of trachoma in relationship to Socio-demographic variables, Girar Jarso Woreda, North
Shoa Zone, Oromia, Ethiopia, 2015.
Characteristics Presence of
Trachoma
Odds Ratio (crude) Adjusted Odds Ratio (AOR) P-value
Yes No
Age
0.2361-4 68 159 1.00 1.00
5-9 148 269 1.286(0.91,1.82) 2.00(0.84,4.99)
Sex

Male 118 236 1.00 1.00 0.262
Female 98 192 1.021(0.74,1.42) 1.28(0.83,1.99)
Climate Condition
0.682Dega(2500m-3500m) 102 220 1.00 1.00
Kola(500m-1500m) 114 208 1.182(0.85,1.64) 1.92(0.75-5.99)
Maternal Educational Status
No education/0/ 196 380 1.00 1.00
0.410Primary /1-8grade/ 13 39 0.646(0.34,1.24) 2.114(0.65,6.81)
Secondary and above/9-12+
grade/ 7 9 1.508(0.55,4.11) 1.892(0.33,11.0)
Family size
0.347< 5 99 216 1.00 1.00
> 5 117 212 1.204(0.87,1.67) 2.54(0.69,3.83)
Average Annual family income
P<0.0001Low <1455birr/month 83 105 1.907(1.34,2.71)** 3.01(1.76,5.14)**
Middle/1455bir to 6380bir/month 131 316 1.00 1.00
High />6380birr/month 2 7 0.689(0.14,3.36) 0.85(0.09,7.96)
Children from shortage access water supply
(<20litre/day/person) were 2.38 times more likely
to have trachoma than sufficient water supply
(>20litre/day/person), (AOR=2.38, 95%CI=1.39-
4.08, p-value=0.002).
The result from washing face and hands with soap
or other substitute had the reduction of trachoma,
(AOR=0.39, 95%CI=0.16-0.94, p-value=0.036).
Of children who had washed their face and hands
twice a day had the fall of trachoma (AOR=0.39,
95%CI=0.17-0.91, p-value=0.03).
The house of children which with any piles of
animal dung/ rubbish lying in open place were 3.37
times more likely to have trachoma than the house
free from animal dung lying in open place.(
AOR=3.37,95%CI=1.59,7.19,p-value=0.002).
Children who were achieved openly defecate free
found to be less likely to have trachoma than who
were openly defecating. (AOR=0.41, 95%CI=0.17-
0.97, p-value =0.042). (Table 6)
Table 6 Prevalence of trachoma in relationship to Sanitation and hygiene status of children, Girar Jarso Woreda,
North Shoa Zone, Oromia, Ethiopia,2015.
Characteristics Presence of
Trachoma
Odds Ratio (crude) Adjusted Odds
Ratio (AOR)
P-
value
Yes No
Type of detergent they use to wash hand and
face
0.036
Only with water 191 271 1.00 1.00
Soap/Ashes 25 157 0.226(0.14,0.36)** 0.39(0.16,0.94)**
Frequency of washing your hand and face

Once a day 159 231 1.00 1.00
0.03Twice a day 54 189 0.423(0.29,0.61)** 0.39(0.17,0.91)**
More than twice 3 8 0.555(0.15,2.13) 0.78(0.07,7.98)
Children triggered CLTSH
0.99No 114 208 1.00 1.00
Yes 102 220 0.846(0.61,1.17) 0.96(0.52,2.45)
Availability of standardize latrine
0.98No 147 222 1.00 1.00
Yes 69 206 0.506(0.39,0.71)** 2.75(0.01,4.75)
Type (options) of latrines
0.98No type to use 147 222 1.00 1.00
Traditional pit Latrine 69 206 0.513(0.36,0.72)** 0.76(0.12,2.65)
Utilize of latrine
0.996No 152 224 1.00 1.00
Yes 64 204 0.462(0.33,0.66)** 0.25(0.14,5.14)
Do Children ODF
0.042No 199 293 1.00 1.00
Yes 17 135 0.185(0.11,0.32)** 0.41(0.17,0.97)**
Discussion
The prevalence rates of all grade of trachoma found
to be 33.4% and active trachoma 27.8%, among
children of age of 1-9 years in the study areas. It
was higher when these figure compared to the
results of other studies, in SNNP (33.2% active
trachoma), Tigray (26.5% active trachoma), Somali
(22.6% active trachoma) and Gambella (19.1%
active trachoma). Also higher than Dembia and
Dabat woreda 29% and 22.4 % and Cheha woreda
Gurage zone (active trachoma 22.4%). Here
trachoma is considered a public health problem
because the active trachoma (TF+TI) prevalence in
children is above 5% (27.8%) and the prevalence of
Trichiasis was greater than 0.1% (3.4%).( (15,28,
29, 34)
Finding from this study showed 391(60.7%)
reported to have shortage daily consumption of
water. Hand and face wash using soap and other
substitute ranged 57% for triggered CLTSH. About
152(47%) were open defecation free in triggered
CLTSH villages. This result showed triggering
CLTSH could increase the percentage of the water,
sanitation and hygiene facilities. (8)
Community led total sanitation and hygiene
triggering by itself did not have association (p-
value=0.99) with reduction of trachoma (i.e. there
is no significance difference between two group of
population The prevalence of trachoma in the two
comparison group had no significant difference and
children in the community led total sanitation and
hygiene triggered village had no lower risk of
trachoma.
Children home exposed to eye irritants, presence of
flies, children who had eyes/nasal discharge and
discharge wiping material, frequency of washing
hands and faces, type of detergent they use, amount
of water per day, average annual family income
and main source of water were found to be
significantly associated with trachoma (p-values
were <0.05 for each factor).Trachoma passed from
the eyes of one person to those of another by flies,
fingers or shared cloths or towels also children
could easily prevented trachoma by washing their
hands and faces regularly with soap or substitute.
Latrine construction and use could also prevent
trachoma. Other many studies well suited with
these findings (2, 6, 9, 14, 15, 30, 32, 33, 34, 36,
38).

Children from low family average monthly income
(<1455bir/month/family) were 3 times more likely
to have trachoma than middle income (1455 to
6380bir/month/family), (AOR=3.00, 95% CI=1.76-
5.14, p-value<0.001). This showed that the burden
of trachoma has fallen disproportionately on poor
rural communities (38).
Children from shortage access water supply
(<20litre/day/person) were 2.38 times more likely
to have trachoma than sufficient water supply
(>20litre/day/person), (AOR=2.38, 95%CI=1.39-
4.08, p-value =0.002). Baggaley et al. in Tanzania
found a strong association greater volume of
available water for general use and thus lower their
risk of active trachoma. Households who allocate
more water for hygiene practices show lower
prevalence of trachoma. A study completed in
Gambia found that, families with trachoma used
less water than those without. According to study
performed in Dembia and Dabat woreda the
shortage of adequate and safe water could have
aggravated the problem of trachoma prevalence in
the rural settings (14, 28, 36).
Washing face and hands with soap or other
substitute had the reduction of trachoma,
(AOR=0.39, 95%CI=0.16-0.94, p-value =0.036).
Study conducted in Ankober showed children with
dirty faces were over 7 times more likely to have
active trachoma than children with clean faces (36).
Of children who had washed their face and hands
twice a day had the fall of trachoma (AOR=0.39,
95%CI=0.17-0.91, p-value=0.03). Study carried out
in Dembia and Dabat woreda and Ankober woreda
depicted that the habit of washing faces more
frequently were observed to be at a lower risk of
acquiring the trachoma than those who did not have
such practices (28, 36).
The house of children which with any piles of
animal dung/ rubbish lying in open place were 3.37
times more likely to have trachoma than the house
free from animal dung lying in open place.(
AOR=3.37,95%CI=1.59,7.19,p-
value=0.002).Finding from south Sudan showed
garbage disposal had trachoma risk reduction of
74.4% also many studies had same association with
this one (2, 14, 15, 28, 32, 33, 36).
Children who were achieved openly defecate free
found to be less likely to have trachoma than who
were openly defecating. (AOR=0.41, 95%CI=0.17-
0.97, p-value =0.042).Most studies did not consider
openly defecation free but they gave attention on
latrine, also in this study area Success of CLTSH
generally had been measured on the basis of
triggering or the number of latrines constructed but
number of latrines available did not show
association with prevalence trachoma in
multivariate analysis rather Openly defecation free
was had great and effective reduction on trachoma
(6, 30, 34).
Conclusion and recommendations
Based on the finding of this study it could be
concluded that there was a higher risk of Active
trachoma but it showed the reduction of trachoma
prevalence by 14.4% in the woreda when it was
compared with last year survey.
The prevalence of trachoma in the two comparison
group had no significant difference, children in the
community led total sanitation and hygiene
triggered village had no lower risk of trachoma
rather encouraging reduction of trachoma in openly
defecation free which was interesting finding and
extraordinary.
This study has indicated a need to give special
attention on quality and full model CLTSH process
(pre triggering, triggering and post triggering) to
achieve openly defecation free and improved
hygiene (facial, hand and environmental
cleanliness) rather than counting number of latrine
constructed, number of pit dug for solid wastes and
number of water facility established.
Acknowledgments
We are pleased to acknowledge the University of
Debremarkos University and GAMBY medical
college for providing ethical approval. We also
extend special thanks to all data collectors,
supervisor and study participants who honestly
shared their time to generate the data required for
the study.
Competing Interests
The authors declare that they have no competing
interests.
Authors’ contribution
The authors’ responsibilities were as follows: TA
designed and supervised the study, carried out
analysis and interpretation of data, BG assisted in
the design, analysis and interpretation of the
data.Both authors read and approved the final
manuscript.

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