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.

Aims: To determine the causes of severe visual impairment and blindness in children in schools for the blind in Ethiopia, to aid in planning for the prevention and management of avoidable causes. Methods: Children attending three schools for the blind in Ethiopia were examined during April and May 2001 using the standard WHO/PBL eye examination record for children with blindness and low vision protocol. Data were analysed for those children aged less than 16 years using the EPI-INFO-6 programme. Results: Among 360 pupils examined, 312 (96.7%) were aged <16 years. Of these children, 295 (94.5%) were blind or severely visually impaired. The major anatomical site of visual loss was cornea/ phthisis (62.4%), followed by optic nerve lesions (9.8%), cataract/aphakia (9.2%), and lesions of the uvea (8.8%). The major aetiology was childhood factors (49.8%). The aetiology was unknown in 45.1% of cases. 68% of cases were considered to be potentially avoidable. Conclusions: Vitamin A deficiency and measles were the major causes of severe visual impairment/ blindness in children in schools for the blind in Ethiopia. The majority of causes acquired during childhood could be avoided through provision of basic primary healthcare services. There are estimated to be 1.4 million blind children worldwide, of whom about 320 000 live in sub-Saharan Africa. The prevalence of blindness in children varies according to socioeconomic development and under 5 years mortality rates, ranging from an estimated 0.3 per 1000 children in high income countries with low under 5 mortality rates to 1.5 per 1000 children in low income countries with high under 5 mortality rates. Although the actual number of blind children is much smaller than the number of adults who are blind, the number of "blind years" resulting from blindness in children is almost equal to the number of blind years due to age related cataract. Furthermore, many of the causes of blindness in children are either preventable or treatable, and are also related to child mortality. Therefore, the control of blindness in children is considered a high priority within the World Health Organization's Vision 2020 initiative: the right to sight. There is a wide regional variation in the causes of blindness and in the cause specific prevalence of blindness. Corneal scarring is the most important cause in the poorest countries of the world. In high income countries, lesions of the central nervous system predominate. In middle income countries the picture is mixed, with retinopathy of prematurity emerging as an important avoidable cause of blindness. In all regions of the world, cataract, retinal diseases, and congenital abnormalities affecting the whole globe are important causes of blindness. 4Ethiopia is a country with a very low socioeconomic status, and children make up almost 50% of its 65 million population. The under 5 years mortality rate is 176/1000 live births, which is unacceptably high even by sub-Saharan standards. 5There is a lack of accurate and reliable recent data on the prev...

In this randomized trial, Saul Rajak et al. compare silk sutures (removed at 7–10 days) or absorbable sutures (left in place) during surgery for the management of trachomatous trichiasis.

SummaryBackgroundEyelid surgery is done to correct trachomatous trichiasis to prevent blindness. However, recurrent trichiasis is frequent. Two procedures are recommended by WHO and are in routine practice: bilamellar tarsal rotation (BLTR) and posterior lamellar tarsal rotation (PLTR). This study was done to identify which procedure gives the better results.MethodsA randomised, controlled, single masked clinical trial was done in Ethiopia. Participants had upper lid trachomatous trichiasis with one or more eyelashes touching the eye or evidence of epilation, in association with tarsal conjunctival scarring. Exclusion criteria were age less than 18 years, recurrent trichiasis after previous surgery, hypertension, and pregnancy. Participants were randomly assigned (1:1) to either BLTR or PLTR surgery, stratified by surgeon. The sequences were computer-generated by an independent statistician. Surgery was done in a community setting following WHO guidelines. Participants were examined at 6 months and 12 months by assessors masked to allocation. The primary outcome was the cumulative proportion of individuals who developed recurrent trichiasis by 12 months. Primary analyses were by modified intention to treat. The intervention effect was estimated by logistic regression, controlled for surgeon as a fixed effect in the model. The trial is registered with the Pan African Clinical Trials Registry (number PACTR201401000743135).Findings1000 participants with trichiasis were recruited, randomly assigned, and treated (501 in the BLTR group and 499 in the PLTR group) between Feb 13, 2014, and May 31, 2014. Eight participants were not seen at either 6 month or 12 month follow-up visits and were excluded from the analysis: three from the PLTR group and five from the BLTR group. The follow-up rate at 12 months was 98%. Cumulative recurrent trichiasis by 12 months was more frequent in the BLTR group than in the PLTR group (110/496 [22%] vs 63/496 [13%]; adjusted odds ratio [OR] 1·96 [95% CI 1·40–2·75]; p=0·0001), with a risk difference of 9·50% (95% CI 4·79–14·16).InterpretationPLTR surgery was superior to BLTR surgery for management of trachomatous trichiasis, and could be the preferred procedure for the programmatic management of trachomatous trichiasis.FundingThe Wellcome Trust.

In this randomized, non-inferiority trial, Saul Rajak et al compare epilation and surgery for the management of minor trichiasis in Ethiopia, the country with the most cases of trachomatous trichiasis.

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Abstract.In collaboration with the health ministries that we serve and other partners, we set out to complete the multiple-country Global Trachoma Mapping Project. To maximize the accuracy and reliability of its outputs, we needed in-built, practical mechanisms for quality assurance and quality control. This article describes how those mechanisms were created and deployed. Using expert opinion, computer simulation, working groups, field trials, progressively accumulated in-project experience, and external evaluations, we developed 1) criteria for where and where not to undertake population-based prevalence surveys for trachoma; 2) three iterations of a standardized training and certification system for field teams; 3) a customized Android phone–based data collection app; 4) comprehensive support systems; and 5) a secure end-to-end pipeline for data upload, storage, cleaning by objective data managers, analysis, health ministry review and approval, and online display. We are now supporting peer-reviewed publication. Our experience shows that it is possible to quality control and quality assure prevalence surveys in such a way as to maximize comparability of prevalence estimates between countries and permit high-speed, high-fidelity data processing and storage, while protecting the interests of health ministries.

Surgical factors are important predictors of unfavorable outcomes in the weeks immediately after surgery. Although the overall rate of serious uncorrectable unfavorable outcomes was very low, the high rate of granuloma formation, which can be treated by removal, highlights the need for follow-up of patients after trichiasis surgery. (ClinicalTrials.gov number, NCT00347776.).