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Original Investigation
November 2017

Surveillance Surveys for Reemergent Trachoma in Formerly Endemic Districts in Nepal From 2 to 10 Years After Mass Drug Administration Cessation

Author Affiliations
  • 1Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, The Johns Hopkins School of Medicine, Baltimore, Maryland
  • 2Nepal Netra Jyoti Sangh, Kathmandu, Nepal
  • 3International Chlamydia Laboratory, Division of Infectious Diseases, The Johns Hopkins School of Medicine, Baltimore, Maryland
  • 4Research Triangle Institute (RTI) International, Washington, DC
JAMA Ophthalmol. 2017;135(11):1141-1146. doi:10.1001/jamaophthalmol.2017.3062
Key Points

Question  Is the World Health Organization recommendation for surveillance surveys to be done 2 years after cessation of mass drug administration in districts formerly endemic for trachoma sufficient to detect reemergence of disease?

Findings  Cross-sectional surveys of 3024 children aged 1 to 9 years were done in 4 districts that were 2, 4, 8, and 10 years, respectively, after mass drug administration. No evidence of reemergence of trachoma or trichiasis exceeding 1 case per 1000 population was identified.

Meaning  These data support the World Health Organization recommendation of surveillance surveys at 2 years after the last mass drug administration.

Abstract

Importance  To verify districts for elimination of blinding trachoma, the World Health Organization requires a population-based surveillance survey for follicular trachoma (TF) and trachomatous trichiasis (TT) 2 years after mass drug administration (MDA) activities have ceased. However, it is unknown if 2 years provides enough time to discover reemergence.

Objective  To determine the prevalence of trachoma from surveys among 4 districts in Nepal (Dailekh, Dang, Surkhet, and Kanchanpur) that had surveillance intervals of 2, 4, 8, and 10 years, respectively, after cessation of MDA.

Design, Setting, and Participants  Cross-sectional surveys were carried out in 2015 and 2016. Data analyses were done from March to September 2016. Among 20 clusters randomly selected from each district, 15 were randomly selected for infection and antibody testing: TF and TT were assessed, conjunctival swabs were tested for chlamydial infection, and blood spots were collected on filter paper to test for antibodies to Chlamydia trachomatis pgp3 using a multiplex bead assay. The study setting was 4 districts previously endemic for trachoma in Nepal. Participants were randomly selected and included 50 children aged 1 to 9 years and 100 adolescents and adults 15 years and older from each of the 20 clusters; this investigation reports on the children.

Main Outcomes and Measures  Length of time since the last round of MDA and the prevalence of TF among children aged 1 to 9 years and the prevalence of TT among adolescents and adults 15 years and older.

Results  Of 3024 children surveyed in the clusters, 48.0% (n = 1452) were female. The mean (SD) age of the children was 5.4 (2.6) years. Eleven cases of TF were found, with a TF prevalence less than 1% in all 4 districts. Three cases of infection were found. Seropositivity for pgp3 antibody varied from 1.4% (95% CI, 0.7-2.6) in the district with a 10-year surveillance interval to 2.5% (95% CI, 1.3-4.5) in the district with a 4-year surveillance interval. Seropositivity increased slightly with age in only one district. The TT prevalence was less than 1 case per 1000 among the total population in all 4 districts after accounting for cases known to the health system and cases with no scarred conjunctiva.

Conclusions and Relevance  This study found no evidence of reemergence of trachoma up to 10 years after cessation of MDA in 4 districts in children in Nepal. The recommendation for a surveillance survey at 2 years, as proposed by the World Health Organization, is supported by these data. Determining if individuals with TT had scarring or are known to the health system was critical for meeting elimination criteria of blinding trachoma.

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