Comparison of two approaches to measuring clean faces as part of the facial cleanliness component of the SAFE trachoma elimination strategy.

BACKGROUND: The Alliance for the Global Elimination of Trachoma (GET) endorses the full SAFE strategy to eliminate trachoma; Surgery (for trichiasis), Antibiotics (to reduce the community pool of infection, Facial cleanliness, and Environmental improvement (to decrease transmission). There is no accepted measure of facial cleanliness. This study compared two possible metrics for facial cleanliness. METHOD/FINDINGS: Metric one: Clean face was defined as observed absence of ocular and nasal discharge on the face. Metric two: observing a grade of dirtiness (scale 10 = lightest to 0 = darkest) on a standard facial wipe. The reliability of grading a child's face or grading a facial wipe was determined in children in Kongwa Tanzania. We also observed both measurements in a cohort of 202 children ages 1 to <7years prior to face cleaning, immediately afterwards, and 4 hours afterwards. Fifty of the children did not have face cleaning and were controls. Intra-and interobserver reliability was similar for both measures, the latter = 0.53 for observing a clean face and 0.52 for grading a facial wipe. There was no correlation between the two. Both measures detected facial cleaning, compared to control children who were not cleaned, immediately after cleaning; control children with 53% clean faces and wipe score of 6.7 compared to cleaned children with 88% clean faces and wipe score of 8 (p = .0001, p = < .0001, respectively). Both measures also detected face washing 4 hours previously compared to controls. CONCLUSIONS: The two metrics were equally reliable, and both measured the behavior of face washing. They measure different aspects of a clean face; one measures the amount of dirt on wiped area and the other measures ocular and nasal discharge. Both measurements appear to capture the behavior of facial cleaning, and the choice of metric would appear to rest on the measurement that captures the stated objective of the behavior, consideration of costs, training, logistics, and implementation.

Gender differences in trachomatous scarring prevalence in a formerly trachoma hyperendemic district in Tanzania.

BACKGROUND: Trachoma is a chronic conjunctivitis caused by the bacterium Chlamydia trachomatis. Repeated infections lead to trachomatous conjunctival scarring which can progress to potentially blinding trachomatous trichiasis (TT). In trachoma hyperendemic conditions, women compared to men have an increased risk of scarring and TT, which can progress to blinding corneal opacification. This study determined if there were gender differences in scarring prevalence and severity when trachoma prevalence approaches elimination, in a formerly trachoma hyperendemic region. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional prevalence study was conducted amongst adults age 15 years and older in Kongwa district, Tanzania in 2019. 3168 persons over age 15 years agreed to be examined and had at least one eye with a gradable image. Ocular photographs were graded for scarring according to a published four-step severity scale. Overall, about half of all study participants had scarring. However, more females (52.3%) had any scarring compared to males (47.2%), OR = 1.22 (95% CI = 1.05-1.43). For every year increase in age, there was a 6.5% increase in the odds of having more severe scarring (95% CI: 5.8%, 7.2%). Women were more likely than men to have severe scarring, OR 2.36 (95% CI: 1.84-3.02). Residence in a community with TF≥10% was associated with a 1.6-fold increased odds of any scarring. CONCLUSIONS/SIGNIFICANCE: Overall scarring prevalence and more severe scarring prevalence was higher in females compared to males, even adjusting for age and community TF prevalence. The data suggest that processes occur that lead to women preferentially progressing towards more severe scarring compared to men.

Comparing image quality and trachoma detection across three camera types from a survey in Kongwa, Tanzania.

BACKGROUND: There is an increasing demand for photography for trachoma prevalence surveys. In previous studies, digital single lens reflex (DSLR) images were superior to smartphone images, but newer-model smartphones and/or lens attachments may be able to bridge this gap. This study compares the image quality and ability to detect trachomatous inflammation - follicular (TF) of three camera types: a DSLR Nikon camera, an iPhone SE and an iPhone 13 Pro with a cell scope. METHODS: We surveyed 62 children ages 1-7 y from two Tanzanian communities. Upper tarsal conjunctiva images of both eyes were graded for TF by two standardized graders. The McNemar's test and a logistic regression model were used for analyses. RESULTS: The DSLR camera malfunctioned during the study, thus the iPhone SE and iPhone 13 Pro with cell scope were both more likely to take high-quality, gradable photographs (88% and 86%, respectively) compared with the DSLR camera (69%) (p<0.001 and p=0.02, respectively). TF was detected in gradable images from the iPhone SE (8.8%) and iPhone 13 Pro with cell scope (9.0%) at the same rate (p=1.0) as images from the DSLR camera (9.7%). CONCLUSION: Smartphones with high-quality image capture, like the iPhone SE/13 Pro, have the potential for use in trachoma surveys if the proportion of gradable images can be improved.

Expanding a photographic grading system for trachomatous scarring.

BACKGROUND: The purpose was to assess an expansion of a previously published photographic four-step severity grading scale for trachomatous scarring (TS). METHODS: Images of everted eyelids of adult women in Tanzania were graded for the presence and severity of TS. The previous S3 grade was subdivided into two categories: S3A, one-third to <50% of the upper eyelid conjunctiva scarred; and S3B, 50% to <90%. The reliability and ease of use were evaluated. This new categorisation was then applied to images taken of the same women 5 y prior to evaluate whether it could help detect previously undetected progression. RESULTS: In total, 142 eyes at baseline and 418 eyes at follow-up after 5 y were graded as S3. Interobserver agreement using the expanded scarring grading scale was a kappa of 0.86. At baseline, 51 (35.9%) eyes were S3A and 91 (64.1%) were S3B. At follow-up after 5 y, 36.6% of the eyes that were previously documented as not having progressed were now detected as having progressed from S3A to S3B. S3B images were more likely to progress to S4 compared with S3A (OR 4.6, 95% CI 2.1 to 9.9). CONCLUSIONS: Adding S3A and S3B is reliable and detects more scarring progression. It will be beneficial for future studies analysing TS in photographs.

Understanding the Role of Gender in Trichiasis Case Finding in Tanzania.

PURPOSE: Despite the importance of trachomatous trichiasis (TT) case-finding activities in national trachoma elimination campaigns, the scientific literature on the determinants of good outcomes - finding and managing all TT cases - is still sparse. In Tanzania, we studied differences in case finding activities and outcomes between male and female case finders. METHODS: This case study was conducted in two districts in Tanzania in 2021-2022. Quantitative data were extracted from case finder forms and outreach registers, and qualitative data were collected through direct observation, interviews, and focus group discussions. RESULTS: Across both districts, more males were trained as case finders (68%). Productivity differences were minor, not statistically significant, between male and female case finders regarding the number of households visited and the number of adults examined. Whether identified by a male or female case finder, similar proportions of men and women suspected to have TT were subsequently managed. There is evidence that suggests that female case finders were more active in supporting suspected and confirmed TT cases to access follow-up services. CONCLUSION: The findings do not suggest that gender balance in the recruitment of TT case finders would have led to better TT campaign outcomes in the study districts. Programmes may benefit from integrating gender considerations in the design and implementation of case finding activities - e.g. in monitoring gender differences among case finders and the relationship with key outcomes. This study also highlights how women with TT face greater barriers to care.

Impact of personal protective equipment on the clarity of vision among trachoma survey graders and trichiasis surgeons in the context of COVID-19.

BACKGROUND/AIMS: The COVID-19 pandemic necessitated the use of personal protective equipment for those involved in trachoma survey grading and trichiasis surgery. We sought to determine which configuration of a face shield would be less likely to impact grading accuracy and ability to conduct trichiasis surgery. The research also included assessment of comfort, ease of cleaning and robustness. METHODS: There were three research phases. In phase 1, assessment of four potential face shield configurations was undertaken with principal trachoma graders and trichiasis surgeon trainers to decide which two options should undergo further testing. In phase 2, clarity of vision and comfort (in a classroom environment) of the two configurations were assessed compared with no face shield (control), while grading trachomatous inflammation-follicular (TF). The second phase also included the assessment of impact of the configurations while performing trichiasis surgery using a training model. In phase 3, face shield ease of use was evaluated during routine surgical programmes. RESULTS: In phase 2, 124 trachoma graders and 28 trichiasis surgeons evaluated the 2 face shield configurations selected in phase 1. TF agreement was high (kappa=0.83 and 0.82) for both configurations compared with not wearing a face shield. Comfort was reported as good by 51% and 32% of graders using the two configurations. Trichiasis skill scores were similar for both configurations. CONCLUSION: The face shield configuration that includes a cut-out for mounting the 2.5× magnifying loupes does not appear to impact the ability or comfort of trachoma graders or trichiasis surgeons to carry out their work.

The Association Between the Severity of Trachomatous Scarring and Trachomatous Trichiasis Severity in Surgical Patients in Tanzania.

PURPOSE: To determine the association between the severity of trachomatous conjunctival scarring (TS) of the upper eyelid conjunctiva and trachomatous trichiasis (TT) severity in TT surgical patients. METHODS: A cross-sectional study was conducted amongst adults with TT who were referred to surgical camps in Bahi District, Tanzania, for TT surgery. Participants underwent ocular examination. The presence and severity of TS was evaluated in photographs of the everted upper eyelid. TT severity was assessed at the time of the ocular exam based on the number of lashes touching the globe and/or evidence and extent of epilation. Ordinal logistic models were used to examine the association between the severity of TS and TT severity. RESULTS: A total of 627 eyes of 388 participants were included. Mean age was 65 years (ranging from 21-98), 81% were females, and 62% had bilateral TT. 93% of eyes with any TT had at least moderate TS; 62% of eyes had severe TS. An increase in TS severity was associated with an increase in the severity of TT. Using as a reference eyes with none to mild TS, in eyes with moderate TS the odds of increased severity of TT was 1.30 (95% CI 0.67-2.51), in eyes with severe TS the odds was 4.20 (95% CI 2.23-7.92). CONCLUSION: In cases of trachomatous trichiasis presenting for surgery, the severity of TT was significantly associated with the severity of TS with almost all cases of TT having moderate or severe scarring.

Comparison of Five Camera Systems for Capturing and Grading Trachoma Images.

PURPOSE: As training of trachoma graders using live participants grows increasingly difficult and expensive, alternative ways are needed possibly through replacement of field grading with photography. However, minimum specifications for a camera system capable of capturing high quality images have not been defined. This study compared images captured using four smartphones with those from a Nikon SLR camera for image quality and assessment of trachomatous inflammation - follicular (TF). METHODS: The smartphones - Samsung Galaxy S8 (S8), Techno Camon 17 pro (TC), Infinix Note 10 pro (IN), Huawei p30 pro (HP) - were chosen for their availability and likelihood of good performance based on specifications without external attachments. All smartphones were used in random order for each participant. RESULTS: 129 children in Kongwa, Tanzania were enrolled (32.8% TF prevalence). The SLR camera had the least percent of ungradable images (3.1%), followed by the S8 (14%), HP (23.4%), IN (65.9%), and TC (71.2%). The S8 and the HP were significantly more likely to take ungradable images if they were used toward the end of the camera rotation. Agreement between the SLR and field grade was kappa = 0.73. Agreement between the field grade and gradable images from the S8 (0.68) and HP (0.8) was measured. CONCLUSIONS: Published specifications did not predict the success of using different smartphones for everted eyelid photographs; proprietary post-processing software likely influenced gradeability. Smartphones, though we cannot recommend those tested in this study, may be viable for capturing images for trachoma provided the quality of images from the field are adequate.

Risk of seroconversion and seroreversion of antibodies to Chlamydia trachomatis pgp3 in a longitudinal cohort of children in a low trachoma prevalence district in Tanzania.

BACKGROUND: Serologic testing for chlamydial antibodies is one potential tool for trachoma monitoring. Understanding the dynamics of seroconversion and seroreversion in low endemic districts is critical for determining the value of using serology. METHODOLOGY/PRINCIPAL FINDINGS: We surveyed a random sample of 2536 children aged 1-9 years in Kongwa, Tanzania, over three years; 1719 (67.8%) participants had all three follow-ups. Surveys assessed trachomatous inflammation-follicular (TF), Chlamydia trachomatis infection, and anti-pgp3 antibodies. Mass drug administration occurred immediately after the first and second follow-up surveys. The cohort was classified into trajectories of change in serostatus, and risk factors were evaluated for seroconversion and seroreversion. We found that 86.2% of seropositives remained seropositive throughout the study, whereas 12.1% seroreverted. Seroreverters were younger (Odds Ratio [OR] = 0.88 for every one-year increase in age, 95% CI = 0.79-0.99). 84.5% of seronegatives remained seronegative, and 13.0% seroconverted. Seroconverters were also younger (OR = 0.92, 95% CI = 0.87-0.98). Seroconversion and seroreversion were not explained by indeterminate values for the intensity of antibody response. Less than 1% of the cohort had unstable changes in serostatus, mostly explained by values in the indeterminate range. TF and infection in the cohort declined over time, while seropositivity increased from 31.5% to 36.4%. CONCLUSIONS/SIGNIFICANCE: Antibody status is relatively stable over time. Both seroconversion and seroreversion occurred over the three years in this low endemic district, especially in younger children. Modeling seroreversion is important for accurate determination of seroconversion. The use of serology as a monitoring tool should target the younger aged children as they will most likely capture recent changes in serostatus.

Productivity, efficiency and gender equity of community mobilisation approaches in trichiasis campaigns: analysis of programmatic data from seven sub-Saharan African countries.

BACKGROUND: Achieving elimination of trachoma as a public health problem in trichiasis-endemic districts requires a systematic approach to trichiasis case finding and outreach. METHODS: Programme monitoring data from seven countries for 2017-2019 were used to explore the efficiency of different community mobilisation approaches and uptake of trichiasis surgical services. RESULTS: Three countries (Ethiopia, Kenya and Mozambique) using broad-based community mobilisation strategies had large numbers of people presenting at outreach but only 2.9% of them had trichiasis, while in four countries (Nigeria, Tanzania, Uganda and Zambia) using house-to-house case finding, 37.5% of outreach attendees had trichiasis. Countries using house-to-house case finding have proportionally more women attending outreach compared with countries using broad-based mobilisation. Among trichiasis cases offered surgery 86% accepted, which was similar for men and women. CONCLUSIONS: In these settings, house-to-house case finding appears to be a more effective and efficient approach to ensure that trichiasis cases, particularly in women, obtain access to surgical services.

The Impact of Image Quality and Trachomatous Inflammation on Using Photography for Trachoma Prevalence Surveys.

Purpose: Graded images can be used for trachoma prevalence surveys, but there is concern for mismatch between image and field grades of the upper tarsal conjunctiva. We aimed to determine if poor photograph quality and/or inflammation may contribute to differential grading of trachomatous inflammation-follicular (TF) between field and photograph graders. Methods: We developed a simplified and expanded image quality grading tool. Agreement was assessed using kappa statistic. We included 5417 eyes with both field and image grades for TF. Eyes where the field and adjudicated photograph TF grades did not match were identified (mismatched) and assigned an image quality (IQ) score and a potential mismatch reason. We also assigned IQ scores to a stratified random sample of 60 eyes with matching field and photograph TF grades (matched). Results: There were 5240 eyes that had matching grades, whereas 177 eyes (3.3%) were mismatched. Overall quality was high, even in mismatched eyes. There was no difference in overall or specific IQ metrics between eyes with matching grades and eyes with mismatched grades (P = 0.59). Mismatched eyes had worse inflammation compared to matched eyes (P = 0.048). The primary reason for calling TF in the field but not in the photographs appeared to be the number of follicles observed. Conclusions: Image quality did not explain mismatch between field grades and image grades from this prevalence survey. Inflammation made mismatch more likely. Translational Relevance: Our quality grading scheme rapidly identifies image quality issues for training. Standardizing TF grading in the presence of inflammation will improve field and photograph grading.

Risk factors for the progression of trachomatous scarring in a cohort of women in a trachoma low endemic district in Tanzania.

BACKGROUND: Trachoma, a chronic conjunctivitis caused by Chlamydia trachomatis, is the leading infectious cause of blindness worldwide. Trachoma has been targeted for elimination as a public health problem which includes reducing trachomatous inflammation-follicular prevalence in children and reducing trachomatous trichiasis prevalence in adults. The rate of development of trachomatous trichiasis, the potentially blinding late-stage trachoma sequelae, depends on the rate of trachomatous scarring development and progression. Few studies to date have evaluated the progression of trachomatous scarring in communities that have recently transitioned to a low trachomatous inflammation-follicular prevalence. METHODOLOGY/PRINCIPAL FINDINGS: Women aged 15 and older were randomly selected from households in 48 communities within Kongwa district, Tanzania and followed over 3.5 years for this longitudinal study. Trachomatous inflammation-follicular prevalence was 5% at baseline and at follow-up in children aged 1-9 in Kongwa, Tanzania. 1018 women aged 15 and older had trachomatous scarring at baseline and were at risk for trachomatous scarring progression; 691 (68%) completed follow-up assessments. Photographs of the upper tarsal conjunctiva were obtained at baseline and follow-up and graded for trachomatous scarring using a previously published four-step severity scale. The overall cumulative 3.5-year progression rate of scarring was 35.3% (95% CI 31.6-39.1). The odds of TS progression increased with an increase in age in women younger than 50, (OR 1.03, 95% CI 1.01-1.05, p = 0.005) as well as an increase in the household poverty index (OR 1.29, 95% CI 1.13-1.48, p = 0.0002). CONCLUSIONS/SIGNIFICANCE: The 3.5-year progression of scarring among women in Kongwa, a formerly hyperendemic now turned hypoendemic district in central Tanzania, was high despite a low active trachoma prevalence. This suggests that the drivers of scarring progression are likely not related to on-going trachoma transmission in this district.

Evaluation of photography using head-mounted display technology (ICAPS) for district Trachoma surveys.

BACKGROUND: As the prevalence of trachoma declines worldwide, it is becoming increasingly expensive and challenging to standardize graders in the field for surveys to document elimination. Photography of the tarsal conjunctiva and remote interpretation may help alleviate these challenges. The purpose of this study was to develop, and field test an Image Capture and Processing System (ICAPS) to acquire hands-free images of the tarsal conjunctiva for upload to a virtual reading center for remote grading. METHODOLOGY/PRINCIPAL FINDINGS: This observational study was conducted during a district-level prevalence survey for trachomatous inflammation-follicular (TF) in Chamwino, Tanzania. The ICAPS was developed using a Samsung Galaxy S8 smartphone, a Samsung Gear VR headset, a foot pedal trigger and customized software allowing for hands-free photography. After a one-day training course, three trachoma graders used the ICAPS to collect images from 1305 children ages 1-9 years, which were expert-graded remotely for comparison with field grades. In our experience, the ICAPS was successful at scanning and assigning barcodes to images, focusing on the everted eyelid with adequate examiner hand visualization, and capturing images with sufficient detail to grade TF. The percentage of children with TF by photos and by field grade was 5%. Agreement between grading of the images compared to the field grades at the child level was kappa = 0.53 (95%CI = 0.40-0.66). There were ungradable images for at least one eye in 199 children (9.1%), with more occurring in children ages 1-3 (18.5%) than older children ages 4-9 (4.2%) (χ2 = 145.3, p<0.001). CONCLUSIONS/SIGNIFICANCE: The prototype ICAPS device was robust, able to image 1305 children in a district level survey and transmit images from rural Tanzania to an online grading platform. More work is needed to improve the percentage of ungradable images and to better understand the causes of disagreement between field and photo grading.

Environmental factors and hygiene behaviors associated with facial cleanliness and trachoma in Kongwa, Tanzania.

BACKGROUND: Having a clean face is protective against trachoma. In the past, long distances to water were associated with unclean faces and increased trachoma. Other environmental factors have not been extensively explored. We need improved clarity on the environmental factors associated with facial cleanliness and trachoma prevalence, especially when the disease burden is low. METHODOLOGY/PRINCIPLE FINDINGS: A cross-sectional survey focusing on household environments was conducted in all 92 villages in Kongwa, Tanzania, in a random selection of 1798 households. Children aged 0-5 years in these households were examined for facial cleanliness. In each of the 50 randomly-selected villages, 50 children aged 1-9 years were randomly selected and examined for trachoma. In a multivariate model adjusting for child age, we found that children were more likely to have clean faces if the house had a clean yard (OR 1.62, 95% CI 1.37-1.91), an improved latrine (OR 1.11, 95% CI 1.01-1.22), and greater water storage capacity (OR 1.02, 95% CI 1.00-1.04), and if there were clothes washed and drying around the house (OR 1.30, 95% CI 1.09-1.54). However, measures of crowding, wealth, time spent on obtaining water, or the availability of piped water was not associated with clean faces. Using a cleanliness index (clean yard, improved latrine, washing clothes, ≥1 child in the household having a clean face), the community prevalence of trachoma decreased with an increase in the average value of the index (OR 2.28, 95% CI 1.17-4.80). CONCLUSIONS/SIGNIFICANCE: Access to water is no longer a significant limiting factor in children's facial cleanliness in Kongwa. Instead, water storage capacity and the way that water is utilized are more important in facial cleanliness. A household cleanliness index with a holistic measure of household environment is associated with reduced community prevalence of trachoma.

Serology, infection, and clinical trachoma as tools in prevalence surveys for re-emergence of trachoma in a formerly hyperendemic district.

BACKGROUND: To eliminate trachoma as a public health problem, countries must achieve a district-level prevalence of trachomatous inflammation-follicular (TF) <5% in children ages 1-9 years. Re-emergence of TF could trigger additional rounds of mass drug/antibiotic administration (MDA), so accurate tools for use in surveys assessing trachoma prevalence are essential. METHODOLOGY & PRINCIPAL FINDINGS: We surveyed 2401 children ages 1-9 years from 50 villages in Kongwa, Tanzania, 2 years post-MDA and 1.5 years after an impact survey found TF <5% in the same villages. Our survey included multiple tools: clinical determination of TF, Cepheid testing for Chlamydia trachomatis infection, and testing for anti-pgp3 antibodies via multiplex bead array. Photographs of the upper tarsal conjunctiva were taken in a subset of children to corroborate the field grades. Overall TF prevalence in 1-9 year olds was 7.1% (95% CI: 5.6%-8.9%), which decreased with age (p = <0.0001). TF prevalence by village was heterogeneous, with 19 villages having TF <5% and 16 villages having TF >10%. There was a strong correlation between field and photo grading of TF (kappa = 0.69; 95% CI: 0.60-0.78) and between TF and infection, with 21.5% of TF-positive children also testing positive for infection, as compared to only 1.6% of TF-negative children (p = 0.0010). Overall seroprevalence was 18.2% (95% CI: 14.8%-22.1%), which increased with age (p = <0.0001). Notably, 1-2 year olds, who were born after the cessation of MDA and theoretically should not have had exposure to C. trachomatis in the absence of transmission, had an average seroprevalence of 6.7%. CONCLUSIONS & SIGNIFICANCE: Field TF prevalence, supported by photographic review and infection data, suggested re-emergence of trachoma in Kongwa. Moreover, seropositivity in the children born after cessation of MDA indicated exposure to C. trachomatis despite a previous survey finding of TF <5%. Examining seropositivity in specific age groups expected to have limited exposure to C. trachomatis can be used to detect re-emergence.

Patient perceived barriers to surgical follow-up: Study of 6-month post-operative trichiasis surgery follow-up in Tanzania.

BACKGROUND: Post-surgical follow-up is a challenge in low- and middle-income countries. Understanding barriers to trachomatous trichiasis (TT) surgical follow-up can inform program improvements. In this study, patient perceived barriers and enabling factors to follow-up after TT surgery are identified. METHODS: A longitudinal study was carried out in a community-based cohort of persons who received TT surgery in Bahi district, Tanzania. Questionnaires were administered before TT surgery and again after the scheduled 6-month follow-up. Those who did not return were examined at their homes. RESULTS: At baseline, 852 participants were enrolled. Of these, 633 (74%) returned at 6 months and 128 (15%) did not and were interviewed at home. Prior to surgery, attenders were more likely to report familiarity with a community health worker (CHW) (22% vs. 14%; p = 0.01) and less likely to state that time constraints are a potential reason for failure to follow-up (66% vs. 74%; p = .04). At follow-up, non-attenders were more likely to endorse barriers pertaining to knowledge about the need for follow-up, lack of transportation, and satisfaction with surgery. There was no difference in post-operative TT between attenders and non-attenders (23% vs. 18% respectively; p = 0.25). CONCLUSIONS: The outcome of surgery was not a barrier to follow-up. However, better integration of CHWs into their communities and work at coordinating post-surgical care may improve follow-up rates. Moreover, provision of transportation and implementation of effective reminder systems may address patient-perceived barriers to improve follow-up.

Children as messengers of health knowledge? Impact of health promotion and water infrastructure in schools on facial cleanliness and trachoma in the community.

BACKGROUND: Health promotion is essential to the SAFE strategy for trachoma elimination. Schools are a valuable venue for health promotion. However, there is little literature about the impact of health education and water infrastructure in schools on facial cleanliness and trachoma in the community. Our study aimed to describe the current state of school health promotion in Kongwa, Tanzania, and to examine the transferability of health messages from schools to the community at large. METHODOLOGY/FINDINGS: A cross-sectional survey was carried out in all 92 villages in Kongwa district, which included 85 primary schools. Data were collected on health messages and water infrastructure in the schools. A random sample of 3084 children aged 0-5 were examined for facial cleanliness in all villages. In 50 villages, a random sample of 50 children aged 1-9 per village were examined for follicular trachoma (TF). Thirty-seven (44.6%) schools had educational materials on face-washing. Fifty (60.2%) schools had a washing station. The presence of a health teacher was correlated with having posters on face washing in classrooms. The presence of face-washing materials was correlated with the availability of washing stations. Neither teachers mentioning face-washing in health curricula nor educational materials in classrooms were associated with clean faces or trachoma in the community. Having a washing station in the school was associated with lower community rates of trachoma. CONCLUSIONS: Primary school health messages and materials on trachoma were not associated with clean faces or lower rates of trachoma in the community. The target audience for primary school health promotion is likely the students themselves, without immediate rippling effects in the community. A long-term perspective should be considered during the implementation of health promotion in schools. The goal of school health promotion should be training the next generation of parents and community health leaders in combatting trachoma.

Incidence and progression of trachomatous scarring in a cohort of children in a formerly hyper-endemic district of Tanzania.

BACKGROUND: Trachoma is the leading infectious cause of blindness. Repeated or persistent ocular infection with Chlamydia trachomatis in childhood leads to conjunctival scarring, usually in adulthood but often earlier in areas with greater disease burden. There are limited longitudinal data examining change in scarring in children, especially where trachoma rates are low. METHODOLOGY/PRINCIPAL FINDINGS: A cohort of children, ages 1-9 years, were randomly selected at baseline from 38 communities in Kongwa, Tanzania and followed for 2 years. Rates of trachomatous inflammation-follicular (TF) were <5% over the survey period. At baseline, 1,496 children were recruited and 1,266 (85%) were followed-up. Photographs were obtained at baseline and follow-up and graded for the presence and severity of scarring using a four-point scale ranging between S1-S4. In children without scarring at baseline, 1.6% (20/1,246) were found to have incident scarring, and incident scarring was more common among girls compared to boys. Among children with scarring at baseline, 21% (4/19) demonstrated progression. CONCLUSIONS/SIGNIFICANCE: In this formerly hyper-endemic district, the incidence of new scarring in children ages 1-9 years is low, although 21% of those who had scarring at baseline progressed in severity over the 2-year follow-up period. These data provide support for the thesis that while incident scarring more closely reflects ongoing exposure, progression may involve factors independent of ongoing transmission of trachoma.

The effect of Mass Drug Administration for trachoma on antibodies to Chlamydia trachomatis pgp3 in children.

A serologic test for antibodies to chlamydia may be a useful tool for trachoma surveillance. However, little is known about the longitudinal stability of antibody status, especially following Mass Drug Administration (MDA), which is critical to understanding serostatus in trachoma-endemic areas. A longitudinal cohort of 1908 children ages 1-9 years in Tanzania from 50 communities were followed at baseline and for 6 months after MDA. They were evaluated for clinical trachoma, conjunctival swabs were tested for chlamydial infection using GeneXpert platform, and blood spots were collected on filter paper and dried to test for antibodies to Chlamydia trachomatis pgp3 using the Luminex platform. 6.3% of children in the study had infection, and coverage with MDA was 97%. 670 (35%) were sero-positive for pgp3 antibodies at baseline, and 4.0% of these seroreverted to negative following MDA. Of those seronegative at baseline, 3.6% seroconverted. The individual change in log median fluorescence intensity(MFI-BG) values was -0.15 overall (p < .001). Seroconversion rates were lower following MDA and seroreversion rates were slightly higher compared to rates in this same cohort in the absence of MDA. MDA has a small effect on reduction of MFI-BG.

Evidence for contamination with C. trachomatis in the household environment of children with active Trachoma: A cross-sectional study in Kongwa, Tanzania.

BACKGROUND: Trachoma, a conjunctivitis caused by repeated infections with Chlamydia trachomatis, remains a significant cause of blindness worldwide. While mass treatments with azithromycin decreases disease and infection, re-emergence occurs, indicating that elimination may require other sustainable interventions. Environmental changes largely focus on facial hygiene and latrines, but further work to identify other possible transmission targets are needed. We sought to determine, in a cross-sectional survey of households of children with active trachoma, if we could detect the presence of Chlamydia trachomatis on household objects and on family members based on sleeping and caretaking patterns. METHODS: In five villages in Kongwa, Tanzania, children