Introduction Trachoma is caused by the bacterium Chlamydia trachomatis (Ct). The WHO recommends the SAFE strategy for trachoma elimination: Surgery for trichiasis, Antibiotics, Facial cleanliness and Environmental improvement. Multiple rounds of SAFE implementation have proven insufficient to eliminate trachoma in Ethiopia, where over 50% of the global trachoma burden remains. More effective antibiotic treatment schedules and transmission-suppressing approaches are needed. The aim of stronger SAFE is to evaluate the impact of a novel package of interventions to strengthen the A, F and E of SAFE on the prevalence of ocular Ct and trachoma in Oromia, Ethiopia.Methods and analysis 68 clusters were randomised in a 1:1:1:1 ratio to one of (1) standard A/standard F&E (standard SAFE), (2) standard A/enhanced F&E, (3) enhanced A/standard F&E or (4) enhanced A/enhanced F&E (stronger SAFE). Enhanced A includes two height-based doses of oral azithromycin (equivalent to 20 mg/kg) given as single doses 2 weeks apart, as mass drug administration, annually. Enhanced F&E includes fly control measures (permethrin-treated headwear and odour-baited traps) and face-washing hygiene behaviour change implemented at household level in selected communities. The interventions will be implemented and reinforced over 3 years.The primary outcome is the prevalence of ocular Ct by quantitative PCR in children aged 1–9 years at 36 months. A key secondary outcome is the prevalence of active (inflammatory) trachoma in the same children, assessed by validated trachoma graders and conjunctival photography. Laboratory technicians and photo-graders are masked to treatment allocation. Other important secondary analyses include process evaluations, assessment of behaviour change, fly indicators, adherence and coverage of interventions and a cost analysis.Ethics and dissemination Study protocols have been approved by the National Research Ethics Review Committee of the Ethiopian Ministry of Science and Higher Education and the London School of Hygiene & Tropical Medicine Ethics Committee. An independent data safety and monitoring board oversees the trial. Results will be disseminated through peer-reviewed publications, presentations and reports.Trial registration number ISRCTN40760473.

OBJECTIVES:A three-arm, open, parallel-group randomised trial compared three face-washing methods for cleaning Chlamydia trachomatis from the faces of children with severe active trachoma. The impact of face-washing on Chlamydia trachomatis on the hands of children and their caregivers and Chlamydia trachomatis duration on faces and hands were investigated as secondary objectives. METHODS:Children aged 1-7 years in Oromia, Ethiopia, were screened for active trachoma. We aimed to recruit 470 children with severe conjunctival inflammation; 141 were expected to have concurrent conjunctival infection and facial Chlamydia trachomatis , detected by qPCR. Those with severe inflammation were randomly assigned to water alone, water with soap or damp, microfibre towel protocols. Swabs (children's faces/hands, caregivers' hands) were collected pre-wash, post-wash, and at 1, 2, 4, 6 and 8 h. Conjunctival swabs were tested for ocular Chlamydia trachomatis infection; only infected children with facial Chlamydia trachomatis were included in primary analysis, comparing the proportion of faces without Chlamydia trachomatis after each washing method. RESULTS:Of 470 children screened with severe inflammation, 25 (5%) had conjunctival infection and facial Chlamydia trachomatis . All three protocols (n = 12 water only, n = 8 water and soap, n = 5 damp towel) reduced discharge, but none removed Chlamydia trachomatis from faces immediately post-wash. No major facial Chlamydia trachomatis load reduction was observed. Face-washing removed Chlamydia trachomatis from some children's and caregivers' hands, but loads were not significantly reduced where Chlamydia trachomatis persisted. Though Chlamydia trachomatis was transiently absent from one face at 1 h and four at 2 h post-wash, all baseline Chlamydia trachomatis -positive children retained it at 8 h. CONCLUSIONS:No evidence of differential or overall effectiveness of the three washing methods at removing facial Chlamydia trachomatis from children with trachoma was found. This finding is limited by a smaller-than-anticipated sample size, potentially hindering detection of subtle differences or overall effects. TRIAL REGISTRATION:ISRCTN registry: ISRCTN12814010 (April 2023).

BACKGROUND:We aimed to determine the household distribution and viability of Chlamydia trachomatis (Ct) from the eyes, face, and hands during the initial two visits of a year-long fortnightly cohort study in geographically defined adjacent households. METHODS/FINDINGS:We enrolled 298 individuals from 68 neighbouring households in Shashemene Woreda, Oromia, Ethiopia. All individuals above 2 years of age residing in these households were examined for signs of trachoma. Swab samples were taken from the conjunctiva, faces, and hands and analysed for the presence and viability of Ct. Ct viability was determined using reverse transcription (RT) PCR. At the initial visit, out of 298 individuals, 133 (44.5%) were children aged 2-9 years. Among these children, 27/133 (20.3%) had trachomatous inflammation-follicular (TF), while 8/133 (6.0%) had trachomatous inflammation-intense (TI). Ct (omcB or pORF2) was detected in 16/133 (12.0%) eye swabs, 14/105 (13.5%) face swabs, and 11/105 (10.5%) hand swabs from children aged 2-9 years. Among these children at visit one, 12/14 (85.7%) with Ct on faces and 9/11 (81.8%) with Ct on hands also had detectable ocular Ct. The severity of the disease worsened from the first visit to the second, and no participants showed clearance of the disease within the two-week period. Ct infection was associated with TF (P = 0.002) and TI (P = 0.060). At visit one, among children aged 2-9 years, viable Ct was detected in 12/16 (75.0%) ocular, 6/14 (42.9%) face, and 4/11 (36.4%) hand swab samples. All viable Ct detected on the faces and hands were identified from individuals with viable ocular infections. Among caregivers whose child tested positive for Ct on their hands, 3 caregivers also had Ct on their hands, accounting for 20% (3 out of 15). Additionally, among caregivers whose child tested positive for Ct on their faces, 2 caregivers had Ct on their faces, which accounts for 14.3% (2 out of 14). In two participants, we detected Ct on the hands of ocular-negative children at the initial visit and later detected ocular Ct at the second visit. CONCLUSION/SIGNIFICANCE:Using RT-qPCR assay to detect Ct omp2 mRNA to define viability offers a new, informative perspective of trachoma transmission in this community in Ethiopia. The presence of viable Ct on the faces and hands of individuals living in households with people with current ocular Ct infection supports the hypothesis that hands and faces are important routes for transmission of trachoma. This highlights the importance of targeted interventions to address these sites of Ct carriage to help interrupt transmission.

Trachoma is targeted for global elimination as a public health problem by 2030. Measurement of IgG antibodies in children is being considered for surveillance and programmatic decision-making. There are currently no programmatic guidelines based on serology, which represents a generalizable problem in seroepidemiology and disease elimination. Here, we collate Chlamydia trachomatis Pgp3 and CT694 IgG measurements from 48 serosurveys across Africa, Latin America, and the Pacific Islands (41,168 children ages 1–5 years) and propose a novel approach to estimate the probability that population C. trachomatis transmission is below or above levels requiring ongoing programmatic action. We determine that trachoma programs could halt control measures with >90% certainty when seroconversion rates (SCRs) are ≤2.2 per 100 person-years. Conversely, SCRs ≥4.5 per 100 person-years correspond with >90% certainty that further control interventions are needed. More extreme SCR thresholds correspond with higher levels of confidence of elimination (lower SCR) or ongoing action needed (higher SCR). This study demonstrates a robust approach for using trachoma serosurveys to guide elimination program decisions.

To assess the prevalence of several parasitic infections in Kiribati, dried blood spots collected during trachoma prevalence surveys in the two major population centers in 2015, 2016, and 2019 were tested using multiplex bead-based serologic assays to detect IgG antibodies against four pathogens of public health interest: Toxoplasma gondii (T. gondii), Taenia solium (T. solium), Strongyloides stercoralis (S. stercoralis), and Toxocara canis (T. canis). In Kiritimati Island, the seroprevalences of T. solium recombinant antigen for detection of cysticercosis antibodies (T24H) and recombinant antigen for detection of taeniasis antibodies (ES33) were ≤4% in both surveys, whereas in Tarawa, the T24H seroprevalence was 2% (2016) and 7% (2019) and the ES33 seroprevalence was ≤3% in both surveys. At both sites, the seropositivity of S. stercoralis recombinant antigen for detection of Strongyloides was 0-4%, and for T. canis, the C-type lectin-1 antigen was 0-1% in all surveys. For T. gondii, the surface antigen glycoprotein 2A antigen seroprevalences on Kiritimati Island were 41% (2015) and 36% (2019), and in Tarawa, they were 36% (2016) and 22% (2019), suggesting that T. gondii infections are common in Kiribati, whereas the other pathogens are not.

To assess the relationship between field-graded trachomatous inflammation—follicular (TF) and other methodologies for evaluating Chlamydia trachomatis ( Ct) transmission intensity. TF has limitations as the sole indicator of Ct transmission for trachoma programmatic decision-making. The relationships between TF and other indicators, including other clinical signs, photography, infection, and serology have yet to be synthesized. A systematic review was conducted. Five databases (MEDLINE, EMBASE, Global Health database, Scopus, and Global Index Medicus) were searched on October 19, 2022, and the e-Theses Online Service was searched on April 12, 2023. Studies from 1987 onward that reported primary data collection of field-graded TF in children and at least one other indicator were included. To compare field-graded vs. photo-graded TF, the mean difference in prevalence and 95% confidence intervals (CIs) were calculated. To compare field-graded TF against the other indicators, weighted correlation coefficients and p-values were calculated in pre-vs. post-antibiotic mass drug administration (MDA) settings. The review protocol was prospectively registered with PROSPERO (CRD42022356013). A total of 35,764 studies were screened, yielding 235 included studies from 49 countries, spanning the years (of data collection) 1991–2021. For field-graded vs. photo-graded TF (n=10), the mean difference in prevalence was 0.7 percentage points, 95% CI (−15.2–16.7). The relationship between TF and other indicators was stronger pre-vs. post-MDA: TF vs infection (R 2 : 0.43, p=0.003 vs. R 2 : 0.002, p=0.788); TF vs seroprevalence (R 2 : 0.56, p<0.001 vs. R 2 : 0.03, p=0.353); and TF vs seroconversion rate (SCR) (R 2 : 0.52, p=0.012 vs. R 2 : 0.26, p=0.061). Post-MDA, infection and SCR were highly correlated (R 2 : 0.71, p=0.001). In studies reporting data used for programmatic decision-making, 48% of the areas warranting MDA based solely on TF had at least one other indicator categorized as indicating “low” or “medium” Ct transmission intensity. The correlation between TF and measures of infection and serology weakens post-initiation of MDA, which is strongly suggestive of poor performance of TF prevalence for guiding programmatic decision-making post-MDA. Measures of infection and SCR are strongly correlated with each other post-MDA. Infection and/or serology should be considered to help guide programmatic decision-making post-MDA. Ophthalmology

PURPOSE:Baseline surveys were conducted in Tigray region, Ethiopia, in 2013. Since then, rounds of azithromycin mass drug administration (MDA) have been delivered in-line with international guidance. The purpose of these surveys was to assess trachomatous inflammation-follicular (TF) prevalence following those treatments to enable the region to plan the next steps towards elimination of trachoma. METHODS:All surveys followed WHO recommendations for community-based cross-sectional survey design. Thirty-one woredas in six zones of Tigray region were surveyed. There were two survey series: all 31 woredas were surveyed in the first series, and 11 woredas were resurveyed in the second, due to having a TF prevalence between 5% and 9.9% in the first series. RESULTS:In the first series of 31 surveys, one woreda had an adjusted TF prevalence in 1-9-year-olds of <5.0%, 13 had a prevalence of 5.0-9.9% and 17 had a prevalence of 10.0-29.9%. In the second series of 11 surveys, the prevalence of TF was <5.0% in seven woredas and 5.0-9.9% in four woredas. The most recent adjusted prevalence of trachomatous trichiasis (TT) unknown to the health system in ≥15-year-olds was ≥.2% in 27 EUs. One-third of households visited had access to an improved drinking water source within a 30-minute return journey of their house, and 11% had an improved latrine. CONCLUSION:Eight woredas met the criteria to stop MDA for 2 years before the re-survey. However, further rounds of MDA, additional efforts to improve water and sanitation access and ongoing strengthening of surgical services for TT are needed across Tigray.

BackgroundTrachoma causes blindness due to repeated conjunctival infection by Chlamydia trachomatis (Ct). Transmission intensity is estimated, for programmatic decision-making, by prevalence of the clinical sign trachomatous inflammation-follicular (TF) in children aged 1-9 years. Research into complementary indicators to field-graded TF includes work on conjunctival photography, tests for ocular Ct infection, and serology. The perceived acceptability and feasibility of these indicators among a variety of stakeholders is unknown.MethodologyFocus group discussions (FGDs) with community members and in-depth interviews (IDIs) with public health practitioners in Tanzania were conducted. FGDs explored themes including participants' experience with, and thoughts about, different diagnostic approaches. The framework method for content analysis was used. IDIs yielded lists of perceived strengths of, and barriers to, implementation for programmatic use of each indicator. These were used to form an online quantitative survey on complementary indicators distributed to global stakeholders via meetings, mailing lists, and social media posts.ResultsSixteen FGDs and 11 IDIs were conducted in October-November 2022. In general, all proposed sample methods were deemed acceptable by community members. Common themes included not wanting undue discomfort and a preference for tests perceived as accurate. Health workers noted the importance of community education for some sample types. The online survey was conducted in April-May 2023 with 98 starting the questionnaire and 81 completing it. Regarding barriers to implementing diagnostics, the highest agreement items related to feasibility, rather than acceptability. No evidence of significant differences was found in responses pertaining to community acceptability based on participant characteristics.ConclusionsAll of the indicators included were generally deemed acceptable by all stakeholders in Tanzania, although community education around the benefits and risks of different sample types, as well as addressing issues around feasibility, will be key to successful, sustainable integration of these indicators into trachoma programs.

PURPOSE:Trachoma is endemic in Kenya. Since baseline trachoma surveys in 2004, a concerted programme has been undertaken to reduce the prevalence of disease. Here, we report on trachoma prevalence surveys carried out between 2017 and 2020 after interventions were implemented in some areas for trachoma elimination purposes. METHODS:A total of 48 cross-sectional population-based trachoma prevalence surveys were conducted in 39 evaluation units (EUs; covering 45 subcounties) of Kenya between 2017 and 2020. Thirty EUs were surveyed once and nine EUs were surveyed twice over this period. Individuals ≥ 1 year old were assessed for trachomatous inflammation-follicular (TF), trachomatous inflammation-intense (TI) and trichiasis. Data were collected on household access to water, sanitation and hygiene (WASH). RESULTS:A total of 147,573 people were examined. At the end of 2020, in the 39 EUs surveyed, the prevalence of TF in 1-9-year-olds was ≥5% in 11 EUs and the prevalence of trichiasis unknown to the health system in individuals aged ≥15 years was ≥0.2% in 25 EUs. A small minority of households (median <50% for all indicators) had access to improved WASH facilities. CONCLUSION:Kenya has made excellent progress towards elimination of trachoma as a public health problem. However, there is more work to do. Between one and three rounds of antibiotic mass drug administration are required in 11 EUs. Sustained investment in surgical provision, continued TT case-finding, promotion of facial cleanliness and environmental improvement are required throughout the surveyed area.

The Rapid Assessment of Avoidable Blindness (RAAB) is a population-based cross-sectional survey methodology used to collect data on the prevalence of vision impairment and its causes and eye care service indicators among the population 50 years and older. RAAB has been used for over 20 years with modifications to the protocol over time reflected in changing version numbers; this paper describes the latest version of the methodology–RAAB7. RAAB7 is a collaborative project between the International Centre for Eye Health and Peek Vision with guidance from a steering group of global eye health stakeholders. We have fully digitised RAAB, allowing for fast, accurate and secure data collection. A bespoke Android mobile application automatically synchronises data to a secure Amazon Web Services virtual private cloud when devices are online so users can monitor data collection in real-time. Vision is screened using Peek Vision’s digital visual acuity test for mobile devices and uncorrected, corrected and pinhole visual acuity are collected. An optional module on Disability is available. We have rebuilt the RAAB data repository as the end point of RAAB7’s digital data workflow, including a front-end website to access the past 20 years of RAAB surveys worldwide. This website (https://www.raab.world) hosts open access RAAB data to support the advocacy and research efforts of the global eye health community. Active research sub-projects are finalising three new components in 2024-2025: 1) Near vision screening to address data gaps on near vision impairment and effective refractive error coverage; 2) an optional Health Economics module to assess the affordability of eye care services and productivity losses associated with vision impairment; 3) an optional Health Systems data collection module to support RAAB’s primary aim to inform eye health service planning by supporting users to integrate eye care facility data with population data.

PURPOSE:The prevalence of trachomatous inflammation-follicular (TF) in Papua New Guinea (PNG) suggests antibiotic mass drug administration (MDA) is needed to eliminate trachoma as a public health problem but the burden of trichiasis is low. As a result, WHO issued bespoke recommendations for the region. If ≥ 20% of 10-14-year-olds have both any conjunctival scarring (C1 or C2 or C3) and corneal pannus and/or Herbert's pits, MDA should be continued. Equally, if ≥ 5% of that group have both moderate/severe conjunctival scarring (C2 or C3) and corneal pannus and/or Herbert's pits, MDA should be continued. METHODS:We identified 14 villages where > 20% of 1-9-year-olds had TF during baseline mapping undertaken 4 years and 1 month previously. Every child aged 10-14 years in those villages was eligible to be examined for clinical signs of corneal pannus, Herbert's pits and conjunctival scarring. A grading system that built on existing WHO grading systems was used. RESULTS:Of 1,293 resident children, 1,181 (91%) were examined. Of 1,178 with complete examination data, only one (0.08%) individual had concurrent scarring and limbal signs. CONCLUSIONS:The WHO-predefined criteria for continuation of MDA were not met. Ongoing behavioural and environmental improvement aspects of the SAFE strategy may contribute to integrated NTD control. Surveillance methods should be strengthened to enable PNG health authorities to identify future changes in disease prevalence.

The Rapid Assessment of Avoidable Blindness (RAAB) is a population-based cross-sectional survey methodology used to collect data on the prevalence of vision impairment and its causes and eye care service indicators among the population 50 years and older. RAAB has been used for over 20 years with modifications to the protocol over time reflected in changing version numbers; this paper describes the latest version of the methodology–RAAB7. RAAB7 is a collaborative project between the International Centre for Eye Health and Peek Vision with guidance from a steering group of global eye health stakeholders. We have fully digitised RAAB, allowing for fast, accurate and secure data collection. A bespoke Android mobile application automatically synchronises data to a secure Amazon Web Services virtual private cloud when devices are online so users can monitor data collection in real-time. Vision is screened using Peek Vision’s digital visual acuity test for mobile devices and uncorrected, corrected and pinhole visual acuity are collected. An optional module on Disability is available. We have rebuilt the RAAB data repository as the end point of RAAB7’s digital data workflow, including a front-end website to access the past 20 years of RAAB surveys worldwide. This website (https://www.raab.world) hosts open access RAAB data to support the advocacy and research efforts of the global eye health community. Active research sub-projects are finalising three new components in 2024-2025: 1) Near vision screening to address data gaps on near vision impairment and effective refractive error coverage; 2) an optional Health Economics module to assess the affordability of eye care services and productivity losses associated with vision impairment; 3) an optional Health Systems data collection module to support RAAB’s primary aim to inform eye health service planning by supporting users to integrate eye care facility data with population data.

Purpose Population-based prevalence surveys are essential for decision-making on interventions to achieve trachoma elimination as a public health problem. This paper outlines the methodologies of Tropical Data, which supports work to undertake those surveys.Methods Tropical Data is a consortium of partners that supports health ministries worldwide to conduct globally standardised prevalence surveys that conform to World Health Organization recommendations. Founding principles are health ministry ownership, partnership and collaboration, and quality assurance and quality control at every step of the survey process. Support covers survey planning, survey design, training, electronic data collection and fieldwork, and data management, analysis and dissemination. Methods are adapted to meet local context and needs. Customisations, operational research and integration of other diseases into routine trachoma surveys have also been supported.Results Between 29th February 2016 and 24th April 2023, 3373 trachoma surveys across 50 countries have been supported, resulting in 10,818,502 people being examined for trachoma.Conclusion This health ministry-led, standardised approach, with support from the start to the end of the survey process, has helped all trachoma elimination stakeholders to know where interventions are needed, where interventions can be stopped, and when elimination as a public health problem has been achieved. Flexibility to meet specific country contexts, adaptation to changes in global guidance and adjustments in response to user feedback have facilitated innovation in evidence-based methodologies, and supported health ministries to strive for global disease control targets.

BACKGROUND In baseline trachoma prevalence surveys, six districts in two governorates of Yemen were identified as requiring interventions. We set out to estimate the prevalence of trachoma 6-12 months after one round of antibiotic mass drug administration (MDA) and implementation of measures to encourage facial cleanliness. METHODS A population-based prevalence survey was conducted in each of the four evaluation units in October 2019. Contemporary World Health Organization recommendations for trachoma surveys were followed. Participants were selected using a two-stage cluster sampling process. The prevalence of inflammatory and late-stage trachoma was measured through eye examination. Water, sanitation, and hygiene facility access among visited households was estimated. RESULTS The prevalence of trachomatous inflammation-,follicular (TF) in 1-9-year-olds per EU was <5.0% in three EUs (Al Mighlaf, Al Munirah, and As Salif; Az Zaydiyah; and Mudhaykhirah districts) and 5.0-9.9% in one EU (Far Al Udayn District). The prevalence of TT unknown to the health system in ≥15-year-olds per EU was <0.2% in all four EUs. Per EU, the proportion of households with an improved drinking water source ranged from 40% to 100%; access to an improved drinking water source within 30-minute return journey of the household ranged from 45% to 100%; and with an improved latrine ranged from 32% to 83%. CONCLUSION An additional round of antibiotic MDA should be administered in Far Al Udayn district before it is resurveyed. In the other surveyed districts, pre-validation surveillance surveys should be conducted in 2 years' time to determine if the TF prevalence <5% has been maintained.

Baseline mapping in the two major population centers of Kiribati showed that trachoma was a public health problem in need of programmatic interventions. After conducting two annual rounds of antibiotic mass drug administration (MDA), Kiribati undertook trachoma impact surveys in 2019, using standardized two-stage cluster surveys in the evaluation units of Kiritimati Island and Tarawa. In Kiritimati, 516 households were visited and in Tarawa, 772 households were visited. Nearly all households had a drinking water source and access to an improved latrine. The prevalence of trachomatous trichiasis remained above the elimination threshold (0.2% in ≥15-year-olds) and was virtually unchanged from baseline. The prevalence of trachomatous inflammation-follicular (TF) in 1-9-year-olds decreased by approximately 40% from baseline in both evaluation units but remained above the 5% TF prevalence threshold for stopping MDA. TF prevalence at impact survey was 11.5% in Kiritimati and 17.9% in Tarawa. Infection prevalence in 1-9-year-olds by PCR was 0.96% in Kiritimati and 3.3% in Tarawa. Using a multiplex bead assay to measure antibodies to the C. trachomatis antigen Pgp3, seroprevalence in 1-9-year-olds was 30.2% in Kiritimati and 31.4% in Tarawa. The seroconversion rate, in seroconversion events/100 children/year, was 9.0 in Kiritimati and 9.2 in Tarawa. Seroprevalence and seroconversion rates were both assessed by four different assays, with strong agreement between tests. These results show that, despite decreases in indicators associated with infection at impact survey, trachoma remains a public health problem in Kiribati, and provide additional information about changes in serological indicators after MDA.

BACKGROUND Following baseline surveys in 2013 and 2014, trachoma elimination interventions, including three rounds of azithromycin mass drug administration (MDA), were implemented in 13 woredas (administrative districts) of Gambella Regional State, Ethiopia. We conducted impact surveys to determine if elimination thresholds have been met or if additional interventions are required. METHODS Cross-sectional population-based surveys were conducted in 13 woredas of Gambella Regional State, combined into five evaluation units (EUs), 6─12 months after their last MDA round. A two-stage systematic (first stage) and random (second stage) sampling technique was used. WHO-recommended protocols were implemented with the support of Tropical Data. Household water, sanitation and hygiene (WASH) access was assessed. RESULTS The age-adjusted prevalence of trachomatous inflammation - follicular (TF) in 1-9-year-olds in the five EUs ranged from 0.3-19.2%, representing a general decline in TF prevalence compared to baseline estimates. The age- and gender-adjusted prevalence of trachomatous trichiasis (TT) unknown to the health system in those aged ≥ 15 years ranged from 0.47-3.08%. Of households surveyed, 44% had access to an improved drinking water source within a 30-minute return journey of the house, but only 3% had access to an improved latrine. CONCLUSION In two EUs, no further MDA should be delivered, and a surveillance survey should be conducted after two years without MDA. In one EU, one further round of MDA should be conducted followed by another impact survey. In two EUs, three further MDA rounds are required. Surgery, facial cleanliness and environmental improvement interventions are needed throughout the region.

Abstract Background The prevalence of sexually transmitted infections (STIs) in sub-Saharan Africa is poorly described. We aimed to determine the prevalence of five treatable STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, Treponema pallidum) in a sample of Gambian women from the general population. Methods Archived specimens from 420 women aged 15 − 69 years living in The Gambia enrolled in a clinical trial of human papilloma virus vaccine schedules were tested in this study. Urine samples were tested for C. trachomatis, N. gonorrhoeae, T. vaginalis and M. genitalium using a commercially available, open-platform multiplex PCR kit. A fragment of the ompA gene was amplified from C. trachomatis-positive samples and sequenced. Serum samples were tested for T. pallidum using the Chembio DPP Syphilis Screen and Confirm test. Results Overall, 41/420 (9.8%) women tested positive for at least one STI. 32 (7.6%), 9 (2.1%), 1 (0.2%), 1 (0.2%) and 0 (0.0%) tested positive for T. vaginalis, C. trachomatis, N gonorrhoeae, M. genitalium and T. pallidum, respectively. ompA gene sequence was available from five C. trachomatis infections: four were genovar D,one was genovar G and one was genovar F. Conclusions STIs are endemic in The Gambia. Monitoring systems should be established.

Background Photography could be used to train individuals to diagnose trachomatous inflammation-follicular (TF) as trachoma prevalence decreases and to ensure accurate field TF grading in trachoma prevalence surveys. We compared photograph and field TF grading and determined the acceptability and feasibility of eyelid photography to community members and trachoma survey trainers.Methods A total of 100 children ages 1-9 y were examined for TF in two Maasai villages in Tanzania. Two images of the right everted superior tarsal conjunctiva of each child were taken with a smartphone and a digital single-lens reflex (DSLR) camera. Two graders independently graded all photos. Focus group discussions (FGDs) were conducted with community members and Tropical Data trainers.Results Of 391 photos, one-fifth were discarded as ungradable. Compared with field grading, photo grading consistently underdiagnosed TF. Compared with field grading, DSLR photo grading resulted in a higher prevalence and sensitivity than smartphone photo grading. FGDs indicated that communities and trainers found photography acceptable and preferred smartphones to DSLR in terms of practicalities, but image quality was of paramount importance for trainers.Conclusions Photography is acceptable and feasible, but further work is needed to ensure high-quality images that enable accurate and consistent grading before being routinely implemented in trachoma surveys.