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As trachoma programs move towards eliminating trachoma as a public health problem, the number of surveys necessary to evaluate the status of trachomatous trichiasis (TT) increases. Currently, the World Health Organization endorses a district-level population-based prevalence survey for trachoma that involves a two-stage cluster design. We explored the validity of implementing this survey design in larger geographic areas to gain cost efficiencies. We evaluated the change in precision due to combining geographically contiguous and homogenous districts into single evaluation units (EUs) and modulating the sample size by running simulations on existing datasets. Preliminary findings from two opportunities in Tanzania show variability in the appropriateness in conducting this survey across larger geographies. These preliminary findings stress the importance of determining what is meant by homogeneity in terms of TT before combining multiple districts into a single EU.

Purpose: Ethiopia is highly trachoma endemic. Baseline mapping was needed in Ethiopia's Somali Region to guide elimination efforts., Methods: Cross-sectional community-based surveys were conducted in 34 suspected trachoma-endemic woredas, grouped as 14 evaluation units (EUs), using a standardised mapping methodology developed for the Global Trachoma Mapping Project., Results: In total, 53,467 individuals were enumerated. A total of 48,058 (89.9%) were present at the time of survey teams' visits and consented to examination. The prevalence of trachomatous inflammation-follicular (TF) among children aged 1-9 years ranged from 4.1% in the EU covering Danot, Boh, and Geladin woredas in Doolo Subzone to 38.1% in the EU covering Kebribeyah and Hareshen woredas in Fafan Subzone (East). The trichiasis prevalence among adults aged over 15   years varied from 0.1% in the EU covering Afder, Bare, and Dolobay woredas in Afder Subzone (West) to 1.2% in the EU covering Awbere in Fafan Subzone (West)., Conclusion: Mass drug administration (MDA) with azithromycin is needed in 13 EUs (population 2,845,818). Two EUs (population 667,599) had TF prevalences in 1-9-year-olds of ≥30% and will require at least 5 years of MDA; 5 EUs (population 1,1193,032) had TF prevalences of 10-29.9% and need at least three years of MDA; 6 EUs (population 985,187) had TF prevalences of 5-9.9% and need at least one round of azithromycin distribution before re-survey. In all 13 of these EUs, implementation of facial cleanliness and environmental improvement measures is also needed. Surveys are still needed in the remaining 34 unmapped woredas of Somali Region.

Purpose: Trachoma is to be eliminated as a public health problem by 2020. To help the process of planning interventions where needed, and to provide a baseline for later comparison, we set out to complete the map of trachoma in Afar, Ethiopia, by estimating trachoma prevalence in evaluation units (EUs) of grouped districts ("woredas")., Methods: We conducted seven community-based surveys from August to October 2013, using standardised Global Trachoma Mapping Project (GTMP) survey methodologies., Results: We enumerated 5065 households and 18,177 individuals in seven EUs covering 19 of Afar's 29 woredas; the other ten were not accessible. 16,905 individuals (93.0%) were examined, of whom 9410 (55.7%) were female. One EU incorporating four woredas (Telalak, Dalefage, Dewe, Hadele Ele) was shown to require full implementation of the SAFE strategy for three years before impact survey, with a trachomatous inflammation-follicular (TF) prevalence in 1-9-year-olds of 17.1% (95%CI 9.4-25.5), and a trichiasis prevalence in adults aged ≥15 years of 1.2% (95%CI 0.6-2.0). Five EUs, covering 13 woredas (Berahle, Aba'ala, Dupti, Kurri, Elidihare, Ayesayeta, Afamboo, Bure Mudaitu, Gewane, Amibara, Dulecho, Dalolo, and Konebo), had TF prevalences in children of 5-9.9% and need one round of azithromycin mass treatment and implementation of the F and E components of SAFE before re-survey; three of these EUs had trichiasis prevalences in adults ≥0.2%. The final EU (Mile, Ada'ar) had a sub-threshold TF prevalence and a trichiasis prevalence in adults just >0.2%., Conclusion: Trachoma is a public health problem in Afar, and implementation of the SAFE strategy is required.

Purpose: The World Health Organization's (WHO's) global trachoma elimination programme recommends mapping of trachoma at district level for planning of elimination activities in affected populations. This study aimed to provide data on trachoma prevalence for the Area Councils of Nigeria's Federal Capital Territory (FCT)., Methods: Using the Global Trachoma Mapping Project (GTMP) protocols, in March and April 2014, we conducted a population-based cross-sectional survey in each of the six Area Councils of FCT. Signs were defined based on the WHO simplified grading scheme., Results: 98% to 100% of the targeted households were enrolled in each Area Council. The number of children aged 1-9 years examined per Area Council ranged from 867 to 1248. The number of persons aged ≥15 years examined ranged from 1302 to 1836. The age-adjusted prevalence of trachomatous inflammation-follicular in 1-9-year-olds was <5% in each Area Council. The age- and gender-adjusted prevalence of trichiasis in those aged ≥15 years ranged from 0.0% to 0.3%; two Area Councils (Gwagwalada and Kwali) had prevalences above the 0.2% elimination threshold. The proportion of households with access to improved latrines and water sources ranged from 17 to 90% and 39 to 85% respectively., Conclusions: Gwagwalada and Kwali Area Councils need to perform more trichiasis surgeries to attain the trichiasis elimination prevalence target of 0.2% in persons aged ≥15 years. No Area Council requires mass antibiotic administration for the purposes of trachoma's elimination as a public health problem. All Area Councils need to accelerate provision of access to improved water sources and latrine facilities, to achieve universal coverage.

Purpose: The purpose of these surveys was to determine the prevalence of trachomatous inflammation-follicular (TF) in children aged 1-9 years and trichiasis prevalence in persons aged ≥15 years, in 13 Local Government Areas (LGAs) of Taraba State, Nigeria., Methods: The surveys followed Global Trachoma Mapping Project (GTMP) protocols. Twenty-five households were selected from each of 25 clusters in each LGA, using two-stage cluster sampling providing probability of selection proportional to cluster size. Survey teams examined all the residents of selected households aged ≥1 year for the clinical signs TF, trachomatous inflammation-intense (TI) and trichiasis., Results: The prevalence of TF in children aged 1-9 years in the 13 LGAs ranged from 0.0-5.0%; Ussa LGA had the highest prevalence of 5% (95%CI: 3.4-7.2). Trichiasis prevalence ranged from 0.0-0.8%; seven LGAs had trichiasis prevalences above the threshold for elimination. The backlog of trichiasis in the 13 LGAs (estimated combined population 1,959,375) was 3,185 people. There is need to perform surgery for at least 1,835 people to attain a trichiasis prevalence in each LGA of <0.2% in persons aged ≥15 years. In six of the 13 LGAs, 80% of households could access washing water within 1 km of the household, but only one LGA had >80% of households with access to improved latrines., Conclusion: One of 13 LGAs requires antibiotic mass drug administration for active trachoma. Community-based trichiasis surgery needs to be provided in seven LGAs. There is a need to increase household-level access to improved washing water and latrines across the State.

Purpose: Surveys are needed to guide trachoma control efforts in Mozambique, with WHO guidelines for intervention based on the prevalence of trachomatous inflammation-follicular (TF) in children aged 1-9 years and the prevalence of trichiasis in adults aged 15 years and above. We conducted surveys to complete the map of trachoma prevalence in Mozambique., Methods: Between July 2012 and May 2015, we carried out cross-sectional surveys in 96 evaluation units (EUs) covering 137 districts., Results: A total of 269,217 individuals were enumerated and 249,318 people were examined using the WHO simplified trachoma grading system. Overall, 102,641 children aged 1-9 years, and 122,689 individuals aged 15 years and above were examined. The prevalence of TF in children aged 1-9 years was ≥10% in 12 EUs, composed of 20 districts, covering an estimated total population of 2,455,852. These districts require mass distribution of azithromycin for at least 3 years before re-survey. The TF prevalence in children was 5.0-9.9% in 17 EUs (28 districts, total population 3,753,039). 22 EUs (34 districts) had trichiasis prevalences ≥0.2% in adults 15 years and above, and will require public health action to provide surgical services addressing the backlog of trichiasis. Younger age, more children resident in the household, and living in a household that had an unimproved latrine or no latrine facility, were independently associated with an increased odds of TF in children aged 1-9 years., Conclusions: Trachoma represents a significant public health problem in many areas of Mozambique.

Purpose: We sought to determine the prevalence of trachoma in 44 Local Government Areas (LGAs) of Kano State, Nigeria., Methods: A population-based prevalence survey was conducted in each Kano LGA. We used a two-stage systematic and quasi-random sampling strategy to select 25 households from each of 25 clusters in each LGA. All consenting household residents aged 1 year and above were examined for trachomatous inflammation-follicular (TF), trachomatous inflammation-intense (TI) and trichiasis., Results: State-wide crude prevalence of TF in persons aged 1-9 years was 3.4% (95% CI 3.3-3.5%), and of trichiasis in those aged ≥15 years was 2.3% (95% CI 2.1-2.4%). LGA-level age- and sex-adjusted trichiasis prevalence in those aged ≥15 years ranged from 0.1% to 2.9%. All but 4 (9%) of 44 LGAs had trichiasis prevalences in adults above the elimination threshold of 0.2%. State-wide prevalence of trichiasis in adult women was significantly higher than in adult men (2.6% vs 1.8%; OR = 1.5, 95% CI 1.3-1.7; p = 0.001). Four of 44 LGAs had TF prevalences in 1-9-year-olds between 10 and 15%, while another six LGAs had TF prevalences between 5 and 9.9%. In 37 LGAs, >80% of households had access to water within 30 minutes round-trip, but household latrine access was >80% in only 19 LGAs., Conclusion: Trichiasis is a public health problem in most LGAs in Kano. Surgeons need to be trained and deployed to provide community-based trichiasis surgery, with emphasis on delivery of such services to women. Antibiotics, facial cleanliness and environmental improvement are needed in 10 LGAs.

Purpose: To complete the baseline trachoma map in Oromia, Ethiopia, by determining prevalences of trichiasis and trachomatous inflammation - follicular (TF) at evaluation unit (EU) level, covering all districts (woredas) without current prevalence data or active control programs, and to identify factors associated with disease., Methods: Using standardized methodologies and training developed for the Global Trachoma Mapping Project, we conducted cross-sectional community-based surveys from December 2012 to July 2014., Results: Teams visited 46,244 households in 2037 clusters from 252 woredas (79 EUs). A total of 127,357 individuals were examined. The overall age- and sex-adjusted prevalence of trichiasis in adults was 0.82% (95% confidence interval, CI, 0.70-0.94%), with 72 EUs covering 240 woredas having trichiasis prevalences above the elimination threshold of 0.2% in those aged ≥15 years. The overall age-adjusted TF prevalence in 1-9-year-olds was 23.4%, with 56 EUs covering 218 woredas shown to need implementation of the A, F and E components of the SAFE strategy (surgery, antibiotics, facial cleanliness and environmental improvement) for 3 years before impact surveys. Younger age, female sex, increased time to the main source of water for face-washing, household use of open defecation, low mean precipitation, low mean annual temperature, and lower altitude, were independently associated with TF in children. The 232 woredas in 64 EUs in which TF prevalence was ≥5% require implementation of the F and E components of the SAFE strategy., Conclusion: Both active trachoma and trichiasis are highly prevalent in much of Oromia, constituting a significant public health problem for the region.

Purpose: Based on health care records and trachoma rapid assessments, trachoma was suspected to be endemic in Kaskazini A and Micheweni districts of Zanzibar. This study aimed to investigate the prevalence of trachomatous inflammation-follicular (TF), and trachomatous trichiasis (TT) in each of those districts., Methods: The survey was undertaken in Kaskazini A and Micheweni districts on Unguja and Pemba Islands, respectively. A multi-stage cluster random sampling design was applied, whereby 25 census enumeration areas (clusters) and 30 households per cluster were included. Consenting eligible participants (children aged 1-9 years and people aged 15 years and older) were examined for trachoma using the World Health Organization simplified grading system., Results: A total of 1673 households were surveyed and 6407 participants (98.0% of those enumerated) were examined for trachoma. Examinees included a total of 2825 children aged 1-9 years and 3582 people aged 15 years and older. TF prevalence in 1-9-year-olds was 2.7% (95% confidence interval, CI, 2.7-4.1%) in Kazkazini A and 11.4% (95% CI 6.6-16.5%) in Micheweni. Among people aged 15 years and older, TT prevalence was 0.01% (95% CI 0.00-0.04%) in Kazkazini A and 0.21% (95% CI 0.08-0.39%) in Micheweni., Conclusion: Trachoma is a public health problem in Micheweni district, where implementation of all four components of the SAFE strategy (surgery, antibiotics, facial cleanliness, and environmental improvement), including mass drug administration with azithromycin, is required. These findings will facilitate planning for trachoma elimination.

Purpose: To determine whether trachoma is a public health problem requiring intervention in Cambodia., Methods: Based on historical evidence and reports, 14 evaluation units (EUs) in Cambodia, judged to be most likely to harbor trachoma, were selected. The Global Trachoma Mapping Project methodology was used to carry out rigorous surveys to determine the prevalence of trachomatous inflammation-follicular (TF) and trichiasis in each EU., Results: The EU-level prevalence of TF among 25,801 1-9-year-old children examined ranged from 0% to 0.2%. Among the 24,502 adults aged 15+ years examined, trichiasis was found in 59 people. Age- and sex-adjusted prevalences of trichiasis in all ages in the EUs studied ranged from 0% to 0.14%; five EUs had a prevalence of trichiasis ≥0.1%., Conclusions: There appears to be no need nor justification at this time for implementing public health measures to control trachoma in Cambodia.

Purpose: Following a first phase of trachoma mapping in Malawi with the Global Trachoma Mapping Project, we identified and mapped trachoma districts previously suspected to be non-endemic, although adjacent to districts with estimated trachoma prevalences indicating a public health problem., Methods: We conducted population-based surveys in eight evaluation units (EUs) comprising eight districts in Malawi (total population 3,230,272). A 2-stage cluster random sampling design allowed us to select 30 households from each of 30 clusters per EU; all residents aged 1 year and older in selected households were examined for evidence of trachomatous inflammation-follicular (TF) and trachomatous trichiasis (TT)., Results: None of the eight EUs had a TF prevalence in 1-9-year-olds ≥10%, one district (Dedza) had a TF prevalence between 5.0% and 9.9%, and only one district (Karonga) had a trichiasis prevalence in adults ≥0.2%., Conclusion: The prevalence of TF and TT in six of eight EUs surveyed was consistent with an original categorization of trachoma being unlikely to be a public health problem. In the absence of formal surveys, health management information system data and other locally available information about trachoma is likely to be useful in predicting areas where public health interventions against trachoma are required.

Introduction: To prepare for global elimination of trachoma by 2020, the World Health Organization (WHO) recommends mapping of trachoma at district-level to enable planning of elimination activities in affected populations. The aim of our study was to provide data on trachoma for each local government area (LGA) of Kaduna State, Nigeria, as such data were previously unavailable., Method: As part of the Global Trachoma Mapping Project (GTMP), a population-based cross-sectional trachoma survey was conducted in each of the 23 LGAs of Kaduna State, between May and June 2013. The protocols of the GTMP were used., Results: The prevalence of trachomatous inflammation - follicular (TF) in children aged 1-9 years was between 0.03% and 8% across the LGAs, with only one LGA (Igabi) having a TF prevalence ≥5%. The LGA-level prevalences of trichiasis in persons aged 15 years and older were between 0.00% and 0.78%. Eleven LGAs had trichiasis prevalences of 0.2% and over in adults; a threshold equivalent to 1 case per 1000 total population. The LGA-level proportion of households with access to improved water sources ranged from 9% to 96%, while household access to latrines ranged from 5% to 99%., Conclusion: Kaduna State has generally hypoendemic trachoma, but a few trichiasis surgeries are still required to attain the WHO elimination targets. Better access to improved water and sanitation is needed.

Purpose: In Ethiopia, trachoma is a major public health problem, accounting for 11.5% of all cases of blindness. In Gambella, one of the country's most remote regions, the 2005-2006 National Survey of Blindness, Low Vision and Trachoma estimated a region-level prevalence of active trachoma of 19.1% in those aged 1-9 years. Detailed district or sub-regional level estimates are required to implement interventions., Methods: Population-based prevalence surveys were carried out following a 2-stage cluster random sampling methodology and Global Trachoma Mapping Project protocols. As the 13 districts (woredas) in Gambella had relatively small populations, they were grouped together to form three evaluation units (EUs) of about 100,000 persons each, and all subsequent survey planning and sampling was carried out at EU-level., Results: Altogether, 558 cases of TF (17.2%) were identified in 3238 children aged 1-9 years across the three EUs. The adjusted TF prevalences in 1-9-year-olds for the three EUs were 11.5%, 12.5% and 19.3%; 14.4% for Gambella overall. A total of 142 cases of trichiasis (3.8%) were identified among 3781 adults aged 15 years or older, with age- and sex-adjusted EU-level trichiasis prevalences in adults being 0.8%, 1.3% and 2.4%; 1.5% overall., Conclusion: The high prevalences of TF and trichiasis throughout Gambella indicate a need for rapid scaling up of the World Health Organization SAFE strategy (surgery, antibiotics, facial cleanliness, and environmental improvement) to help meet the 2020 target of global elimination of trachoma as a public health problem.

Purpose: Trachoma is a major cause of blindness in Ethiopia, and targeted for elimination as a public health problem by the year 2020. Prevalence data are needed to plan interventions. We set out to estimate the prevalence of trachoma in each evaluation unit of grouped districts ("woredas") in Benishangul Gumuz region, Ethiopia., Methods: We conducted seven cross-sectional community-based surveys, covering 20 woredas, between December 2013 and January 2014, as part of the Global Trachoma Mapping Project (GTMP). The standardized GTMP training package and methodologies were used., Results: A total of 5828 households and 21,919 individuals were enumerated in the surveys. 19,583 people (89.3%) were present when survey teams visited. A total of 19,530 (99.7%) consented to examination, 11,063 (56.6%) of whom were female. The region-wide age- and sex-adjusted trichiasis prevalence in adults aged ≥15 years was 1.3%. Two evaluation units covering four woredas (Pawe, Mandura, Bulen and Dibate) with a combined rural population of 166,959 require implementation of the A, F and E components of the SAFE strategy (surgery, antibiotics, facial cleanliness and environmental improvement) for at least three years before re-survey, and intervention planning should begin for these woredas as soon as possible., Conclusion: Both active trachoma and trichiasis are public health problems in Benishangul Gumuz, which needs implementation of the full SAFE strategy.

Purpose: To complete the baseline trachoma map worldwide by conducting population-based surveys in an estimated 1238 suspected endemic districts of 34 countries., Methods: A series of national and sub-national projects owned, managed and staffed by ministries of health, conduct house-to-house cluster random sample surveys in evaluation units, which generally correspond to "health district" size: populations of 100,000-250,000 people. In each evaluation unit, we invite all residents aged 1 year and older from h households in each of c clusters to be examined for clinical signs of trachoma, where h is the number of households that can be seen by 1 team in 1 day, and the product h × c is calculated to facilitate recruitment of 1019 children aged 1-9 years. In addition to individual-level demographic and clinical data, household-level water, sanitation and hygiene data are entered into the purpose-built LINKS application on Android smartphones, transmitted to the Cloud, and cleaned, analyzed and ministry-of-health-approved via a secure web-based portal. The main outcome measures are the evaluation unit-level prevalence of follicular trachoma in children aged 1-9 years, prevalence of trachomatous trichiasis in adults aged 15 + years, percentage of households using safe methods for disposal of human feces, and percentage of households with proximate access to water for personal hygiene purposes., Results: In the first year of fieldwork, 347 field teams commenced work in 21 projects in 7 countries., Conclusion: With an approach that is innovative in design and scale, we aim to complete baseline mapping of trachoma throughout the world in 2015.