The Morges Strategy for Yaws Eradication: the first largescale Total Community Treatment with azithromycin against yaws in the Congo-Basin, using a novel model.

Context and Justification. Yaws is targeted for eradication by 2030. Total Community Treatment with azithromycin (TCT), a major component of the eradication strategy, has witnessed only three pilots since 2012.  We implemented the first large-scale TCT in the Congo-Basin of Central Africa using a novel model. Methodology. We implemented a novel 3-phase TCT model 17 health districts of the Congo-Basin, spanning 3 countries. Two rounds were implemented in Cameroon, and one round each in Central African Republic (CAR) and the Republic of Congo; targeting 1,530,014 people (144,934(9.5%) Pygmies and 1,304,410(90.5%) Bantus). TCT was followed by post-campaign active surveillance, treatment of yaws cases and their contacts. Results. All 17 health districts were confirmed for yaws endemicity. Overall, 1,456,691 (95.21%; 95%CI: 95.17%-95.24%) persons were treated in the first round of TCT, including 552,356/594411 (92.92%; 95%CI: 92.86%-92.99%) in Cameroon, 359,810/373,994 (96.21%; 95%CI: 96.15%-96.27%) in CAR, and 544,526/561,609 (96.96%; 95%CI: 96.91%-97.00%) in Congo. For the second round implemented only in Cameroon, 615,503/642,947 (95.73%; 95%CI: 95.68%-95.78%) were treated. There was a 3-percentage-point increase in therapeutic coverage between the first and second round (P-value<0.001), and from 89.2% to 93.1% (P-value<0.001) among the Pygmies. The prevalence of active yaws decreased from 6.5% to 0.4% (P-value<0.001) overall, and from 6.31% to 0.23% (P-value<0.001, OR=28.67, 95%CI (20.86-40.09) in Cameroon, from 2.4% to 0.8% (P-value=0.002, OR=3.19, 95% CI: 1.45-8.00) in CAR,  and from 10.8% to 3.7% (P-value<0.001, OR=3.18, 95%CI: 2.09 – 5.01) in Congo. Conclusion. A novel TCT model was successfully implemented at largescale in the Congo-Basin, achieving above recommended threshold of therapeutic coverages. The prevalence of active yaws dropped remarkably following the TCT, however complete interruption of yaws transmission was not achieved. In recommending the novel model of TCT to endemic countries, we suggest that at least three rounds, at six-monthly intervals, are implemented for complete interruption of yaws transmission. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The author(s) received no specific funding for this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The intervention was approved by the Cameroon National Ethics Committee for Research in Human Health, and the Ethics Committee for Research in Health Sciences of the Republic of Congo. Administrative authorisations were also obtained from the ministries of health in the three countries involved in the intervention. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All relevant data are within the manuscript and its Supporting Information files.

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