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Trachoma programs use annual antibiotic mass drug administration (MDA) in evaluation units (EUs) that generally encompass 100,000–250,000 people. After one, three, or five MDA rounds, programs undertake impact surveys. Where impact survey prevalence of trachomatous inflammation—follicular (TF) in 1- to 9-year-olds is ≥ 5%, ≥ 1 additional MDA rounds are recommended before resurvey. Impact survey costs, and the proportion of impact surveys returning TF prevalence ≥ 5% (the failure rate or, less pejoratively, the MDA continuation rate), therefore influence the cost of eliminating trachoma. We modeled, for illustrative EU sizes, the financial cost of undertaking MDA with and without conducting impact surveys. As an example, we retrospectively assessed how conducting impact surveys affected costs in the United Republic of Tanzania for 2017–2018. For EUs containing 100,000 people, the median (interquartile range) cost of continuing MDA without doing impact surveys is USD 28,957 (17,581–36,197) per EU per year, whereas continuing MDA solely where indicated by impact survey results costs USD 17,564 (12,158–21,694). If the mean EU population is 100,000, then continuing MDA without impact surveys becomes advantageous in financial cost terms only when the continuation rate exceeds 71%. For the United Republic of Tanzania in 2017–2018, doing impact surveys saved enough money to provide MDA for > 1,000,000 people. Although trachoma impact surveys have a nontrivial cost, they generally save money, providing EUs have > 50,000 inhabitants, the continuation rate is not excessive, and they generate reliable data. If all EUs pass their impact surveys, then we have waited too long to do them.

Achieving elimination of lymphatic filariasis (LF) as a public health problem requires a minimum of five effective rounds of mass drug administration (MDA) and demonstrating low prevalence in subsequent assessments. The first assessments recommended by the World Health Organization (WHO) are sentinel and spot-check sites—referred to as pre-transmission assessment surveys (pre-TAS)—in each implementation unit after MDA. If pre-TAS shows that prevalence in each site has been lowered to less than 1% microfilaremia or less than 2% antigenemia, the implementation unit conducts a TAS to determine whether MDA can be stopped. Failure to pass pre-TAS means that further rounds of MDA are required. This study aims to understand factors influencing pre-TAS results using existing programmatic data from 554 implementation units, of which 74 (13%) failed, in 13 countries. Secondary data analysis was completed using existing data from Bangladesh, Benin, Burkina Faso, Cameroon, Ghana, Haiti, Indonesia, Mali, Nepal, Niger, Sierra Leone, Tanzania, and Uganda. Additional covariate data were obtained from spatial raster data sets. Bivariate analysis and multilinear regression were performed to establish potential relationships between variables and the pre-TAS result. Higher baseline prevalence and lower elevation were significant in the regression model. Variables statistically significantly associated with failure (p-value ≤0.05) in the bivariate analyses included baseline prevalence at or above 5% or 10%, use of Filariasis Test Strips (FTS), primary vector of Culex, treatment with diethylcarbamazine-albendazole, higher elevation, higher population density, higher enhanced vegetation index (EVI), higher annual rainfall, and 6 or more rounds of MDA. This paper reports for the first time factors associated with pre-TAS results from a multi-country analysis. This information can help countries more effectively forecast program activities, such as the potential need for more rounds of MDA, and prioritize resources to ensure adequate coverage of all persons in areas at highest risk of failing pre-TAS., Author summary Achieving elimination of lymphatic filariasis (LF) as a public health problem requires a minimum of five rounds of mass drug administration (MDA) and being able to demonstrate low prevalence in several subsequent assessments. LF elimination programs implement sentinel and spot-check site assessments, called pre-TAS, to determine whether districts are eligible to implement more rigorous population-based surveys to determine whether MDA can be stopped or if further rounds are required. Reasons for failing pre-TAS are not well understood and have not previously been examined with data compiled from multiple countries. For this analysis, we analyzed data from routine USAID and WHO reports from Bangladesh, Benin, Burkina Faso, Cameroon, Ghana, Haiti, Indonesia, Mali, Nepal, Niger, Sierra Leone, Tanzania, and Uganda. In a model that included multiple variables, high baseline prevalence and lower elevation were significant. In models comparing only one variable to the outcome, the following were statistically significantly associated with failure: higher baseline prevalence at or above 5% or 10%, use of the FTS, primary vector of Culex, treatment with diethylcarbamazine-albendazole, lower elevation, higher population density, higher Enhanced Vegetation Index, higher annual rainfall, and six or more rounds of mass drug administration. These results can help national programs plan MDA more effectively, e.g., by focusing resources on areas with higher baseline prevalence and/or lower elevation.

Purpose: Following surveys in 2004–2006 in 50 high-risk districts of mainland Tanzania, trachoma was still suspected to be widespread elsewhere. We report on baseline surveys undertaken from 2012 to 2014. Methods: A total of 31 districts were surveyed. In 2012 and 2013, 12 at-risk districts were selected based on proximity to known trachoma endemic districts, while in 2014, trachoma rapid assessments were undertaken, and 19 of 55 districts prioritized for baseline surveys. A multi-stage cluster random sampling methodology was applied whereby 20 villages (clusters) and 36 households per cluster were surveyed. 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 23,171 households were surveyed and 104,959 participants (92.3% of those enumerated) examined for trachoma signs. A total of 44,511 children aged 1–9 years and 65,255 people aged 15 years and older were examined for trachomatous inflammation–follicular (TF) and trichiasis, respectively. Prevalence of TF varied by district, ranging from 0.0% (95% confidence interval, CI 0.0–0.1%) in Mbinga to 11.8% (95% CI 6.8–16.5%) in Chunya. Trichiasis prevalence was lowest in Urambo (0.03%, 95% CI 0.00–0.24%) and highest in Kibaha (1.08%, 95% CI 0.74–1.43%). Conclusion: Only three districts qualified for mass drug administration with azithromycin. Trichiasis is still a public health problem in many districts, thus community-based trichiasis surgery should be considered to prevent blindness due to trachoma. These findings will facilitate achievement of trachoma elimination objectives.

Global health practitioners are increasingly advocating for the integration of community-based health-care platforms as a strategy for increasing the coverage of programs, encouraging program efficiency, and promoting universal health-care goals. To leverage the strengths of compatible programs and avoid geographic and temporal duplications in efforts, the Tanzanian Ministry of Health and Social Welfare coordinated immunization and neglected tropical disease programs for the first time in 2014. Specifically, a measles and rubella supplementary vaccine campaign, mass drug administration (MDA) of ivermectin and albendazole, and Vitamin A were provisionally integrated into a shared community-based delivery platform. Over 21 million people were targeted by the integrated campaign, with the immunization program and MDA program reaching 97% and 93% of targeted individuals, respectively. The purpose of this short report is to share the Tanzanian experience of launching and managing this integrated campaign with key stakeholders.

To compare diagnostic tests for onchocerciasis in a setting that has suppressed transmission, a randomized, age-stratified study was implemented in an area in Tanzania that had received 15 rounds of annual mass drug administration (MDA) with ivermectin. Study participants (N = 948) from 11 villages underwent a questionnaire, skin examination, skin snips, and blood draw. The burden of symptomatic disease was low. Ov-16 antibody rapid diagnostic test (RDT) results were positive in 38 (5.5%) participants, with 1 (0.5%), 1 (0.4%), and 2 (0.8%) in children aged 0–5, 6–10, and 11–15 years, respectively. Despite significant impact of MDA on transmission, the area would have failed to meet World Health Organization serologic criteria for stopping MDA if a full evaluation had been conducted. The specificity of the RDT, which is 97–98%, may result in the identification of a number of false positives that would exceed the current stop MDA threshold.

Endemicity mapping is required to determining whether a district requires mass drug administration (MDA). Current guidelines for mapping LF require that two sites be selected per district and within each site a convenience sample of 100 adults be tested for antigenemia or microfilaremia. One or more confirmed positive tests in either site is interpreted as an indicator of potential transmission, prompting MDA at the district-level. While this mapping strategy has worked well in high-prevalence settings, imperfect diagnostics and the transmission potential of a single positive adult have raised concerns about the strategy’s use in low-prevalence settings. In response to these limitations, a statistically rigorous confirmatory mapping strategy was designed as a complement to the current strategy when LF endemicity is uncertain. Under the new strategy, schools are selected by either systematic or cluster sampling, depending on population size, and within each selected school, children 9–14 years are sampled systematically. All selected children are tested and the number of positive results is compared against a critical value to determine, with known probabilities of error, whether the average prevalence of LF infection is likely below a threshold of 2%. This confirmatory mapping strategy was applied to 45 districts in Ethiopia and 10 in Tanzania, where initial mapping results were considered uncertain. In 42 Ethiopian districts, and all 10 of the Tanzanian districts, the number of antigenemic children was below the critical cutoff, suggesting that these districts do not require MDA. Only three Ethiopian districts exceeded the critical cutoff of positive results. Whereas the current World Health Organization guidelines would have recommended MDA in all 55 districts, the present results suggest that only three of these districts requires MDA. By avoiding unnecessary MDA in 52 districts, the confirmatory mapping strategy is estimated to have saved a total of $9,293,219., Author summary Mapping is used by lymphatic filariasis (LF) elimination programs to determine if mass drug administration (MDA) is required. The current mapping approach, designed to be simple and practical, has worked well in high-prevalence settings but concerns about its reliability in low-prevalence settings have been raised. To address these concerns, a confirmatory mapping strategy was developed that utilizes probability-based sampling of school attending children to determine if the prevalence of LF antigenemia is below a 2% threshold. The confirmatory mapping strategy was implemented in 45 districts in Ethiopia and 10 in Tanzania where the need for MDA was uncertain. In 52 of the 55 districts, the number of LF antigen-positive children identified by the confirmatory mapping strategy was below the predetermined threshold and MDA was deemed unnecessary, while in three districts the number of positive children exceeded the threshold, suggesting that MDA is required. The use of this mapping strategy, to confirm whether MDA is required, is estimated to have saved the Ethiopian and Tanzanian programs $9,293,219 by avoiding unnecessary MDA in 52 districts.