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.

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.

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.

The "F" in SAFE: Reliability of assessing clean faces for trachoma control in the field.

BACKGROUND: Although facial cleanliness is part of the SAFE strategy for trachoma there is controversy over the reliability of measuring a clean face. A child's face with no ocular and nasal discharge is clean and the endpoint of interest, regardless of the number of times it must be washed to achieve that endpoint. The issue of reliability rests on the reproducibility of graders to assess a clean face. We report the reproducibility of assessing a clean face in a field trial in Kongwa, Tanzania. METHODS/FINDINGS: Seven graders were trained to assess the presence and absence of nasal and ocular discharge on children's faces. Sixty children ages 1-7 years were recruited from a community and evaluated independently by seven graders, once and again about 50 minutes later. Intra-and inter-observer variation was calculated using unweighted kappa statistics. The average intra-observer agreement was kappa = 0.72, and the average inter-observer agreement was kappa = 0.78. CONCLUSIONS: Intra-observer and inter-observer agreement was substantial for the assessment of clean faces using trained Tanzania staff who represent a variety of educational backgrounds. As long as training is provided, the estimate of clean faces in children should be reliable, and reflect the effort of families to keep ocular and nasal discharge off the faces. These data suggest assessment of clean faces could be added to trachoma surveys, which already measure environmental improvements, in districts.