Prevalence of Trachoma in Pakistan: Results of 42 Population-Based Prevalence Surveys from the Global Trachoma Mapping Project

Purpose: Previous phases of trachoma mapping in Pakistan completed baseline surveys in 38 districts. To help guide national trachoma elimination planning, we set out to estimate trachoma prevalence in 43 suspected-endemic evaluation units (EUs) of 15 further districts.

Methods: We planned a population-based trachoma prevalence survey in each EU. Two-stage cluster sampling was employed, using the systems and approaches of the Global Trachoma Mapping Project. In each EU, residents aged ≥1 year living in 30 households in each of 26 villages were invited to be examined by trained, certified trachoma graders. Questionnaires and direct observation were used to evaluate household-level access to water and sanitation.

Results: One EU was not completed due to insecurity. Of the remaining 42, three EUs had trichiasis prevalence estimates in ≥15-year-olds ≥0.2%, and six (different) EUs had prevalence estimates of trachomatous inflammation—follicular (TF) in 1–9-year-olds ≥5%; each EU requires trichiasis and TF prevalence estimates below these thresholds to achieve elimination of trachoma as a public health problem. All six EUs with TF prevalences ≥5% were in Khyber Pakhtunkhwa Province. Household-level access to improved sanitation ranged by EU from 6% to 100%. Household-level access to an improved source of water for face and hand washing ranged by EU from 37% to 100%.

Conclusion: Trachoma was a public health problem in 21% (9/42) of the EUs. Because the current outbreak of extremely drug-resistant typhoid in Pakistan limits domestic use of azithromycin mass drug administration, other interventions against active trachoma should be considered here.

Quality Assurance and Quality Control in the Global Trachoma Mapping Project

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.

Trachoma in Viet Nam: results of 11 surveillance surveys conducted with the Global Trachoma Mapping Project

Purpose: Following interventions against trachoma in Viet Nam, impact surveys conducted in 2003–2011 suggested that trachoma was no longer a public health problem. In 2014, we undertook surveillance surveys to estimate prevalence of trachomatous inflammation—follicular (TF) and trichiasis.

Methods: A population-based prevalence survey was undertaken in 11 evaluation units (EUs) encompassing 24 districts, using Global Trachoma Mapping Project methods. A two-stage cluster sampling design was used in each EU, whereby 20 clusters and 60 children per cluster were sampled. Consenting eligible participants (children aged 1–9 years and adults aged ≥50 years) were examined for trachoma.

Results: A total of 9391 households were surveyed, and 20,185 participants (98.8% of those enumerated) were examined for trachoma. EU-level TF prevalence in 1–9-year-olds ranged from 0% to 1.6%. In one cluster (in Hà Giang Province), the percentage of children with TF was 10.3%. The overall pattern of cluster-level percentages of children with TF, however, was consistent with an exponential distribution, which would be consistent with trachoma disappearing. Among people aged ≥50 years, prevalence of trichiasis by EU ranged from 0% to 0.75%; these estimates are equivalent to 0–0.13% in all ages. The prevalence of trichiasis unknown to the health system among people aged ≥50 years, by EU, ranged from 0% to 0.17%, which is equivalent to 0–0.03% in all ages.

Conclusion: Findings suggest that trachoma is no longer a public health problem in any of the 11 EUs surveyed. However, given the high proportion of children with TF in one cluster in Hà Giang Province, further investigations will be undertaken.

Prevalence of and risk factors for trachoma in Kwara state, Nigeria: Results of eight population-based surveys from the Global Trachoma Mapping Project

Purpose: To determine the prevalence of and risk factors for trachoma in selected local government areas (LGAs) of Kwara State, Nigeria.

Methodology: Population-based cross-sectional surveys were conducted in eight LGAs of Kwara State using Global Trachoma Mapping Project (GTMP) protocols. In each LGA, 25 villages were selected using probability-proportional-to-size sampling; 25 households were selected from each village using compact segment sampling. All residents of selected households aged ≥1 year were examined by GTMP-certified graders for trachomatous inflammation—follicular (TF) and trichiasis using the simplified trachoma grading scheme. Water, sanitation, and hygiene (WASH) data were also collected.

Results: A total of 28,506 residents were enumerated in 4769 households across the eight LGAs. TF prevalence in children aged 1–9 years ranged from 0.2% (95% CI 0.0–0.3%) to 1.3% (95% CI 0.7–2.1%), while trichiasis prevalence in persons ≥15 years was <0.2% in each LGA. Access to improved water source was the lowest in Edu (62%), while access to improved sanitation facilities was the lowest in Asa (6%) and the highest in Ilorin East (64%). Children aged 1–4 years had 0.63 (95% CI 0.40–0.99) times lower odds of having TF compared to children aged 5–9 years. Children in households with ≥5 resident 1–9-year-old children had 1.63 (95% CI 1.02–2.60) times greater odds of having TF compared to those in households with <5 resident children.

Conclusion: Trachoma is not a public health problem in Kwara State. Provision of adequate water and sanitation services should be a priority here, as a foundation for the health of the population.

Impact Survey Results after SAFE Strategy Implementation in 15 Local Government Areas of Kebbi, Sokoto and Zamfara States, Nigeria

Purpose: To determine prevalence of trachoma after interventions in 15 local government areas (LGAs) of Kebbi, Sokoto and Zamfara States, Nigeria.

Methods: A population-based impact survey was conducted in each LGA using Global Trachoma Mapping Project (GTMP) protocols. In each LGA, 25 villages were selected, except in Arewa LGA, where we selected 25 villages from each of four subunits to obtain finer-resolution prevalence information. Villages were selected with probability proportional to size. In each village, 25 households were enrolled and all consenting residents aged ≥1 year were examined by GTMP-certified graders for trachomatous inflammation—follicular (TF) and trachomatous trichiasis (TT). Information on sources of household water and types of sanitation facilities used was collected through questioning and direct observation.

Results: The number of households enrolled per LGA ranged from 623 (Kware and Tangaza) to 2488 (Arewa). There have been marked reductions in the prevalence of TF and TT since baseline surveys were conducted in all 15 LGAs. Eight of the 15 LGAs have attained TF prevalences <5% in children, while 10 LGAs have attained TT prevalences <0.2% in persons aged ≥15 years. Between 49% and 96% of households had access to water for hygiene purposes within 1 km of the household, while only 10–59% had access to improved sanitation facilities.

Conclusion: Progress towards elimination of trachoma has been made in these 15 LGAs. Collaboration with water and sanitation agencies and community-based trichiasis surgery are still needed in order to eliminate trachoma by the year 2020.

Prevalence of trachoma in Yemen: results of population-based prevalence surveys of 42 evaluation units in nine governorates

Purpose: In suspected trachoma-endemic areas of Yemen, we sought to determine the prevalence of the sign trachomatous inflammation—follicular (TF) in children aged 1–9 years, and the potential individual and household risk factors for TF in that age group. We also sought to determine the prevalence of trichiasis in adults aged ≥15 years.

Methods: We conducted a cluster-sampled survey in each of 42 evaluation units (EUs) comprising 166 rural districts of nine Governorates (Adh Dhale’a, Al Hodeihah, Al Jawf, Hadramoot, Hajjah, Ibb, Lahj, Ma’rib, Taiz) using the Global Trachoma Mapping Project systems and methodologies. Fieldwork was undertaken from September 2013 to March 2015. Risk factors for TF in children aged 1–9 years were evaluated using multilevel random effects logistic regression.

Results: The TF prevalence in children aged 1–9 years was ≥10% in two EUs (7 districts) and 5–9.9% in six EUs (24 districts). In adults aged ≥15 years, trichiasis prevalence was ≥0.2% in five EUs (19 districts). Being older (within the 1–9-year age bracket), being male, living in a household with higher numbers of children, and living in a household that reported the use of open defecation, were each independently associated with higher odds of TF.

Conclusions: These surveys provided baseline data to enable planning for trachoma elimination. The World Health Organization Alliance for the Global Elimination of Trachoma by 2020 stands ready to assist Yemen once security considerations permit further surveys and implementation of control activities.

Prevalence of Trachoma and Access to Water and Sanitation in Benue State, Nigeria: Results of 23 Population-Based Prevalence Surveys

Purpose: We sought to determine the prevalence of trachoma in each local government area (LGA) of Benue State, Nigeria.

Methods: Two-stage cluster sampling was used to conduct a series of 23 population-based prevalence surveys. LGAs were the evaluation units surveyed. In each LGA, 25 households were selected in each of 25 clusters, and individuals aged 1 year and above resident in those households were invited to be examined for trachoma. Data on access to water and sanitation were also collected at household level.

Results: A total of 91,888 people were examined from among 93,636 registered residents across the 23 LGAs. The LGA-level prevalence of trachomatous inflammation—follicular (TF) in 1–9 year olds ranged from 0.3% to 5.3%. Two LGAs had TF prevalences of 5.0–9.9%. The LGA-level prevalence of trichiasis in ≥15-year-olds ranged from 0.0% to 0.35%. Access to improved drinking water sources ranged from 0% in Gwer West to 99% in Tarka, while access to improved sanitation ranged from 1% in Gwer West to 92% in Oturkpo.

Conclusion: There is a need for public health-level interventions against trachoma in three LGAs of Benue State.

Prevalence of trachoma in 13 Local Government Areas of Taraba State, Nigeria

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.

Prevalence of trachoma in the Afar Region of Ethiopia: results of seven population-based surveys from the Global Trachoma Mapping Project

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.

Sanitation and water supply coverage thresholds associated with active trachoma: Modeling cross-sectional data from 13 countries

BACKGROUND

Facial cleanliness and sanitation are postulated to reduce trachoma transmission, but there are no previous data on community-level herd protection thresholds. We characterize associations between active trachoma, access to improved sanitation facilities, and access to improved water sources for the purpose of face washing, with the aim of estimating community-level or herd protection thresholds.

METHODS AND FINDINGS

We used cluster-sampled Global Trachoma Mapping Project data on 884,850 children aged 1-9 years from 354,990 households in 13 countries. We employed multivariable mixed-effects modified Poisson regression models to assess the relationships between water and sanitation coverage and trachomatous inflammation-follicular (TF). We observed lower TF prevalence among those with household-level access to improved sanitation (prevalence ratio, PR = 0.87; 95%CI: 0.83-0.91), and household-level access to an improved washing water source in the residence/yard (PR = 0.81; 95%CI: 0.75-0.88). Controlling for household-level water and latrine access, we found evidence of community-level protection against TF for children living in communities with high sanitation coverage (PR80-90% = 0.87; 95%CI: 0.73-1.02; PR90-100% = 0.76; 95%CI: 0.67-0.85). Community sanitation coverage levels greater than 80% were associated with herd protection against TF (PR = 0.77; 95%CI: 0.62-0.97)-that is, lower TF in individuals whose households lacked individual sanitation but who lived in communities with high sanitation coverage. For community-level water coverage, there was no apparent threshold, although we observed lower TF among several of the higher deciles of community-level water coverage.

CONCLUSIONS

Our study provides insights into the community water and sanitation coverage levels that might be required to best control trachoma. Our results suggest access to adequate water and sanitation can be important components in working towards the 2020 target of eliminating trachoma as a public health problem.

Prevalence of Trachoma in Kano State, Nigeria: Results of 44 Local Government Area-Level Surveys

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.

Mapping Trachoma in Kaduna State, Nigeria: Results of 23 Local Government Area-Level, Population-Based Prevalence Surveys

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.

Prevalence of Trachoma in Gambella Region, Ethiopia: Results of Three Population-Based Prevalence Surveys Conducted with the Global Trachoma Mapping Project

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.

Prevalence of Trachoma in Benishangul Gumuz Region, Ethiopia: Results of Seven Population-Based Surveys from the Global Trachoma Mapping Project

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.

Prevalence of and Risk Factors for Trachoma in Oromia Regional State of Ethiopia: Results of 79 Population-Based Prevalence Surveys Conducted with the Global Trachoma Mapping Project

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.

Completion of Baseline Trachoma Mapping in Malawi: Results of Eight Population-Based Prevalence Surveys Conducted with the Global Trachoma Mapping Project

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.

Low Prevalence of Ocular Chlamydia trachomatis Infection and Active Trachoma in the Western Division of Fiji

Background

Trachoma is the leading infectious cause of blindness and is caused by ocular infection with the bacterium Chlamydia trachomatis (Ct). While the majority of the global disease burden is found in sub-Saharan Africa, the Western Pacific Region has been identified as trachoma endemic. Population surveys carried out throughout Fiji have shown an abundance of both clinically active trachoma and trachomatous trichiasis in all divisions. This finding is at odds with the clinical experience of local healthcare workers who do not consider trachoma to be highly prevalent. We aimed to determine whether conjunctival infection with Ct could be detected in one administrative division of Fiji.

Methods

A population-based survey of 2306 individuals was conducted using the Global Trachoma Mapping Project methodology. Population prevalence of active trachoma in children and trichiasis in adults was estimated using the World Health Organization simplified grading system. Conjunctival swabs were collected from 1009 children aged 1–9 years. DNA from swabs was tested for the presence of the Ct plasmid and human endogenous control.

Results

The prevalence of active trachoma in 1–9 year olds was 3.4%. The age-adjusted prevalence was 2.8% (95% CI: 1.4–4.3%). The unadjusted prevalence of ocular Ct infection in 1–9 year-olds was 1.9% (19/1009), and the age-adjusted infection prevalence was 2.3% (95% CI: 0.4–2.5%). The median DNA load was 41 Ct plasmid copies per swab (min 20, first quartile 32, mean 6665, third quartile 161, max 86354). There was no association between current infection and follicular trachoma. No cases of trachomatous trichiasis were identified.

Discussion

The Western Division of Fiji has a low prevalence of clinical trachoma. Ocular Ct infections were observed, but they were predominantly low load infections and were not correlated with clinical signs. Our study data suggest that trachoma does not meet the WHO definition of a public health problem in this Division of Fiji, but the inconsistency with previous studies warrants further investigation.

Trachoma, caused by ocular strains of Chlamydia trachomatis, represents a major global public health issue, and is the subject of an international elimination campaign. Until recently, data on trachoma in the Pacific Island states have been sparse. The most recent studies have conflicted in their estimates of trachomatous disease burden in Fiji, therefore, surveys using alternative markers (infection testing plus grading) to those already used (grading alone) are warranted to try to shed further light on trachoma epidemiology in this setting. We used an externally validated clinical assessment protocol to show that evidence of active trachoma is present at a low prevalence, and we did not find any cases of trichiasis, the sight-threatening stage of trachoma. From testing of conjunctival swabs with a validated, next-generation PCR, we also found that C. trachomatis was present at a low prevalence. Our clinical data suggest that trachoma does not meet the WHO definition of a public health problem in this Division of Fiji, but the inconsistency with previous studies warrants further investigation.

The Global Trachoma Mapping Project: Methodology of a 34-Country Population-Based Study

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.

Baseline Trachoma Mapping in Malawi with the Global Trachoma Mapping Project (GTMP)

Purpose: To determine the prevalence of trachoma in all suspected endemic districts in Malawi.

Methods: A population-based survey conducted in 16 evaluation units from 12 suspected endemic districts in Malawi (population 6,390,517), using the standardized Global Trachoma Mapping Project (GTMP) protocol. A 2-stage cluster-random sampling design selected 30 households from each of 30 clusters per evaluation unit; all residents aged 1 year and older in selected households were examined for evidence of follicular trachoma (TF), intense trachomatous inflammation (TI), and trachomatous trichiasis (TT).

Results: Four of the 16 evaluation units were found to be endemic for trachoma, with a prevalence range of 10.0–13.5% for TF and 0.2–0.6% for TT. Nine evaluation units had a TF prevalence between 5.0% and 9.9% while three evaluation units had a TF prevalence <5.0%.

Conclusion: The prevalence rates of active trachoma in Malawi were not uniform among suspected endemic evaluation units, with rates higher than the World Health Organization (WHO) threshold for implementation of community-based control measures (TF ≥ 10.0%) in only 4 of the 16 evaluation units. Trachoma remains a disease of public health importance in some parts of Malawi and adjoining (unmapped) districts should be prioritized for mapping. According to the survey, an additional 3,169,362 people require intervention to reduce active disease and 1557 trichiasis surgeries are needed to reduce the prevalence of TT below WHO recommended thresholds.

The association of race/ethnicity, insurance status, and socioeconomic factors with breast cancer care

BACKGROUND

Few data are available on how race/ethnicity, insurance, and socioeconomic status (SES) interrelate to influence breast cancer treatment. The authors examined care for a national cohort of breast cancer patients to assess whether insurance and SES were associated with racial/ethnic differences in care.

METHODS

The authors used multivariate logistic regression to assess the probability of definitive locoregional therapy, hormone receptor testing, and adjuvant systemic therapy among 662,117 white, black, and Hispanic women diagnosed with invasive breast cancer during 1998-2005 at National Cancer Data Base hospitals. In additional models, the authors included insurance and area-level SES to determine whether these variables were associated with observed racial/ethnic disparities.

RESULTS

Most women were white (86%), 10% were black, and 4% were Hispanic. Most had private insurance (51%) or Medicare (41%). Among eligible patients, 80.0% (stage I/II) had definitive locoregional therapy, 98.5% (stage I-IV) had hormone receptor testing, and 53.1% and 50.2% (stage I-III) received adjuvant hormonal therapy and chemotherapy, respectively. After adjustment, black (vs white) women had less definitive locoregional therapy (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.88-0.94), hormonal therapy (OR, 0.90; 95% CI, 0.87-0.93), and chemotherapy (OR, 0.87; 95% CI, 0.84-0.91). Hispanic (vs white) women were also less likely to receive hormonal therapy. Hormone receptor testing did not differ by race/ethnicity. Racial disparities persisted despite adjusting for insurance and SES.

CONCLUSIONS

The modest association between black (vs white) race and guideline-recommended breast cancer care was insensitive to adjustment for insurance and area-level SES. Further study is required to better understand disparities and to ensure receipt of care.

Disparities associated with advanced prostate cancer stage at diagnosis

This study expands on a previous report (focusing on health insurance status and race/ethnicity) to present effects of age, socioeconomic status, hospital type, and other factors (e.g., type of Medicaid and Medicare coverage, insurance-by-race/ethnicity interactions) on advanced-stage (III/IV) at prostate cancer diagnosis. Invasive (Stages I-IV) prostate cancer cases diagnosed during 1998-2004 were extracted from the National Cancer Database (N=687,464). Independent of health-insurance and race/ethnicity, socioeconomic status was a significant predictor of advanced stage at diagnosis, with patients residing in areas with lower socioeconomic characteristics having significantly increased odds. Those treated at community-cancer-centers had significantly decreased odds (versus teaching/research-facilities). Significantly increased odds were also observed among uninsured-Blacks, Medicare-insured-Blacks, Medicaid-insured-Blacks, Medicare-insured-Hispanics, and Medicare-insured-other-racial/ethnic-minorities 65 years old and older (versus corresponding White-populations). The impact of prostate cancer screening on reducing mortality remains debatable. Still, our results suggest improvements in multiple factors that affect access-to-care may achieve earlier diagnosis and, therefore, a potentially more treatable disease.

Factors associated with colon cancer stage at diagnosis

We analyzed data from 1998-2004 from the National Cancer Data Base to evaluate associations between patient/treatment facility factors and stage at diagnosis for all colon cancers combined and by anatomic location. Compared to patients with private insurance, uninsured patients were significantly more likely to present with advanced-stage disease; Medicaid patients had likelihoods of advanced-stage colon cancer in-between those of privately insured and uninsured patients. Increased odds of advanced-stage colon cancer at diagnosis were also observed among Black (vs. White) patients, women (vs. men), and patients from low socioeconomic status (SES) regions (vs. those from higher SES regions). While the likelihood of advanced-stage disease at diagnosis decreased in later years overall, this decrease was not observed among patients with ascending colon cancers. Screening disparities may lead to more advanced stage at diagnosis among colon cancer patients; programs to improve access to screening among underserved populations may address this disparity.

Insurance status, comorbidity level, and survival among colorectal cancer patients age 18 to 64 years in the National Cancer Data Base from 2003 to 2005

PURPOSE

Previous analyses have found that insurance status is a strong predictor of survival among patients with colorectal cancer aged 18 to 64 years. We investigated whether differences in comorbidity level may account in part for the association between insurance status and survival.

METHODS

We used 2003 to 2005 data from the National Cancer Data Base, a national hospital-based cancer registry, to examine the relationship between baseline characteristics and overall survival at 1 year among 64,304 white and black patients with colorectal cancer. In race-specific analyses, we used Cox proportional hazards models to assess 1-year survival by insurance status, controlling first for age, stage, facility type, and neighborhood education level and income, and then further controlling for comorbidity level. RESULTS; Comorbidity level was lowest among those with private insurance, higher for those who were uninsured or insured by Medicaid, and highest for those insured by Medicare. Survival at 1 year was significantly poorer for patients without private insurance, even after adjusting for important covariates. In these multivariate models, risk of death at 1 year was approximately 50% to 90% higher for white and black patients without private insurance. Further adjustment for number of comorbidities had only a modest impact on the association between insurance status and survival. In multivariate analyses, patients with > or = three comorbid conditions had approximately 40% to 50% higher risk of death at 1 year. CONCLUSION Among white and black patients aged 18 to 64 years, differences in comorbidity level do not account for the association between insurance status and survival in patients with colorectal cancer.

Paraoxonase 1 (PON1) polymorphisms and prostate cancer in the CPS-II Nutrition Cohort

BACKGROUND

The HDL-associated enzyme paraoxonase 1 acts to decrease oxidative stress, which is thought to contribute to cancer development. PON1, which encodes paraoxonase 1, has two common, nonsynonymous SNPs that alter the activity of this enzyme and may influence cancer risk.

METHODS

We investigated the association the nonsynonymous SNPs, Q192R and L55M, with prostate cancer risk in a nested case-control analysis of 1,268 cases and 1,268 matched controls from the American Cancer Society CPS-II Nutrition Cohort.

RESULTS

For both the Q192R and L55MSNPs, the presence of the variant allele was associated with an increased risk of aggressive prostate cancer that approached statistical significance. The genotype combination that included one variant allele from both SNPs (QR/LM) was associated with an increased risk of more than twofold (OR = 2.18, 95% CI: 1.31, 3.64).

CONCLUSIONS

These findings suggest that the Q129R and the L55M SNP may be associated with increased risk of aggressive prostate, perhaps through attenuation of paraoxonase l activity.

Association of polymorphisms in one-carbon metabolism genes and postmenopausal breast cancer incidence

The interconversion of folates by the one-carbon metabolism pathway is essential for the synthesis of precursors used in DNA synthesis, repair, and methylation. Perturbations in this pathway can disrupt these processes and are hypothesized to facilitate carcinogenesis. We investigated associations of 25 candidate polymorphisms in nine one-carbon metabolism genes with risk of postmenopausal breast cancer using 502 cases and 505 controls from the Cancer Prevention II Nutrition Cohort. Four single nucleotide polymorphisms (SNP) in three different genes were significantly associated with breast cancer. The nonsynonymous R134K SNP in methylenetetrahydrofolate dehydrogenase/methenyltetrahydrofolate cyclohydrolase/formyltetrahydrofolate synthase [MTHFD1; odds ratio (OR), 1.40; 95% confidence interval (95% CI), 1.06-1.85 for CT + TT] and an intronic SNP in formyltetrahydrofolate dehydrogenase (FTHFD; OR, 2.23; 95% CI, 1.09-4.54 for CC) were associated with a significant increase in risk. Significantly decreased risk was associated with an intronic SNP in FTHFD (OR, 0.75; 95% CI, 0.58-0.98 for CT + CC) and the A360A SNP in cystathionine beta-synthase (CBS; OR, 0.63; 95% CI, 0.41-0.96 for TT). The presence of at least one variant from both the methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C SNPs was also associated with increased risk (OR, 2.16; 95% CI, 1.34-3.48 for 677 CT + TT/1,298 AC + CC). Investigations into interactions of the associated SNPs with each other and with dietary factors yielded inconclusive results. Our findings indicate that genetic variation in multiple one-carbon metabolism genes may influence risk of postmenopausal breast cancer and may involve changes in methyl donor synthesis. However, larger studies are needed to further examine gene/gene and gene/diet interactions in this pathway.

Lack of evidence for effect modification by estrogen of association between body mass index and colorectal cancer risk among postmenopausal women

OBJECTIVE

Previous studies of the association between body mass index (BMI) and colorectal cancer among women found increased risk only among women who were premenopausal or used hormone replacement therapy (HRT). These results led to the hypothesis that BMI may increase risk more strongly among women with higher levels of circulating estrogen. We examined the association between BMI and colorectal cancer incidence by use of HRT, and number of postmenopausal years without HRT, a measure of duration of exposure to lower levels of estrogen.

METHODS

During follow-up from 1992-2003, 814 incident colorectal cancer cases were identified among 73,842 postmenopausal women in the Cancer Prevention Study-II Nutrition Cohort. Information on BMI and other risk factors was obtained from questionnaires completed at enrollment in 1992-1993 and during follow-up. Hazard ratios were calculated using proportional hazards modeling.

RESULTS

The association between BMI and colorectal cancer incidence was similar among never-users of HRT (hazard ratio 1.13, 95% confidence interval 1.02-1.25 per 5-unit increase in BMI) and current-users of HRT (hazard ratio 1.08, 95% confidence interval 0.92-1.27 per 5-unit increase in BMI). Among women not currently using HRT, the association between BMI and colorectal cancer did not differ by postmenopausal years without HRT.

CONCLUSIONS

Our results do not support the hypothesis that BMI increases risk of colorectal cancer more strongly among women with higher levels of estrogen.

Glycemic load, glycemic index, and carbohydrate intake in relation to pancreatic cancer risk in a large US cohort

BACKGROUND

Consumption of diets with high glycemic load has been hypothesized to increase pancreatic cancer risk by raising postprandial glucose levels and insulin secretion.

METHODS

The authors analyzed data from the American Cancer Society Cancer Prevention Study II (CPS-II) Nutrition Cohort to examine the association between pancreatic cancer and glycemic load, glycemic index (GI), and intake of carbohydrates. Diet was assessed among 124,907 men and women who were cancer-free and non-diabetic at baseline in 1992 using a validated 68-item food frequency questionnaire (FFQ). During 9 years of follow-up, 401 incident pancreatic cancer cases were identified. Cox proportional hazards modeling was used to compute hazard rate ratios (RR) adjusted for potential confounding factors.

RESULTS

We found no association between glycemic load, GI, or carbohydrate intake and risk of pancreatic cancer in this population. The hazard rate ratio (RR) was 1.01 (95% CI 0.75-1.37, trend P=0.80) for glycemic load, 0.92 (95% CI 0.68-1.24) for GI, and 1.10 (95% CI 0.80-1.51) for carbohydrate intake among men and women in the highest quintile compared to the lowest quintile of each measure. We also found no significant association between these measures and pancreatic cancer risk among individuals who show a greater susceptibility towards insulin insensitivity, such as those who are overweight or more sedentary.

CONCLUSION

Overall, our data do not support the hypothesis that glycemic load or index, or carbohydrate intake are associated with a substantial increase in pancreatic cancer risk; however, a weak positive association cannot be ruled out.

Nested case-control study of energy regulation candidate gene single nucleotide polymorphisms and breast cancer

BACKGROUND

Accumulating evidence suggests that energy regulation, particularly insulin resistance, may influence breast cancer risk.

MATERIALS AND METHODS

The associations between single nucleotide polymorphisms (SNPs) in energy regulation candidate genes and postmenopausal breast cancer risk were evaluated. Conditional logistic regression was run on 488 matched case-control pairs from the American Cancer Society's Cancer Prevention Study II Nutrition Cohort. The studied SNPs were INS+1127 PstI (rs3842752), INSR H1085H (rs1799817) and PPARy Prol2Ala (rs1801282).

RESULTS

A significantly lower breast cancer risk was found among women homozygous for the T allele of INSR H1085H. A marginally significant increased risk of breast cancer was observed among women homozygous for the Ala allele of PPARgamma Pro12Ala. No significant association was observed between INS+ 1127 PstI and breast cancer risk.

CONCLUSION

Our results suggest that polymorphisms in these energy regulation candidate genes may be associated with risk of breast cancer, but replication in larger studies is needed.

Association of Polymorphisms in the Paraoxonase 1 Gene with Breast Cancer Incidence in the CPS-II Nutrition Cohort

Paraoxonase 1 (PON1) plays an important role in the high-density lipoprotein-mediated prevention of low-density lipoprotein oxidation and the metabolism of lipid-soluble radicals. In this study, we investigated the association of two common, nonsynonymous polymorphisms in the PON1 gene (Q192R and L55M) with breast cancer risk in postmenopausal women through a nested case-control study within the American Cancer Society Cancer Prevention Study II Nutrition Cohort. Using conditional logistic regression of genotyping results from 502 cases and 502 cancer-free controls matched on age, race/ethnicity, and date of blood draw, we found that the L55M single nucleotide polymorphism (SNP) was associated with an increased risk of breast cancer [odds ratio (OR), 1.58; 95% confidence interval (95% CI), 1.05-2.37 for MM]. No association was found for the Q192R SNP. The L55M association with breast cancer was modified by nonsteroidal anti-inflammatory drug (NSAID) use. The association was limited to women who took NSAIDs and was somewhat stronger among women who reported regular (> or = 15 times per month) NSAID use (OR, 3.24; 95% CI, 1.17-9.00) than in those who reported any NSAID use (OR, 2.46; 95% CI, 1.39-4.36). These results suggest that genetic variation in PON1, particularly at the L55M SNP, may be associated with increased risk of breast cancer in postmenopausal women. Furthermore, NSAID use seems to modify this risk.

Folate nutrition and prostate cancer incidence in a large cohort of US men

Folate has important roles in DNA synthesis, repair, and methylation and is inversely associated with the risk of some cancers. The authors examined this association among 65,836 men in the American Cancer Society Cancer Prevention Study II Nutrition Cohort. During 9 years of follow-up, 5,158 men were diagnosed with prostate cancer. Folate intakes were estimated from the questionnaire administered at enrollment in 1992-1993, and Cox proportional hazards models were used to calculate hazard rate ratios adjusted for potential confounders. Neither dietary nor total folate intake was associated with prostate cancer overall. However, higher folate levels were associated with a nonsignificant decreased risk of advanced prostate cancer (multivariate rate ratio=0.78, 95% confidence interval: 0.53, 1.15 for the highest vs. lowest quintiles of dietary folate and rate ratio=0.79, 95% confidence interval: 0.54, 1.17 for the highest vs. lowest quintile of total folate). The association was similar for quintiles 2-5, suggesting that only a small increase in folate intake was needed to alter the risk of advanced prostate cancer. Because the statistical power of the analysis with advanced prostate cancer was limited by the low number of cases, further study is needed to establish this association.

Recreational physical activity and sedentary behavior in relation to ovarian cancer risk in a large cohort of US women

Factors that influence circulating sex hormones, such as physical activity, have been proposed to influence ovarian cancer risk; however, results from previous epidemiologic studies have been inconsistent. The authors examined the association among physical activity, sedentary behavior, and ovarian cancer risk in the American Cancer Society Cancer Prevention Study II Nutrition Cohort, a prospective study of cancer incidence and mortality, using information obtained at baseline in 1992. From 1992 to 2001, 314 incident ovarian cancer cases were identified among 59,695 postmenopausal women who were cancer free at enrollment. Cox proportional hazards modeling was used to compute hazard rate ratios while adjusting for potential confounders. No overall association was observed between measures of past physical activity or with recreational physical activity at baseline and risk of ovarian cancer in this study (for the highest category of physical activity compared with none: hazard rate ratio = 0.73, 95% confidence interval: 0.40, 1.34). However, a prolonged duration of sedentary behavior was associated with an increased risk (for > or = 6 vs. < 3 hours per day: hazard rate ratio = 1.55, 95% confidence interval: 1.08, 2.22; p(trend) = 0.01). Results from this study suggest that high levels of sedentary behavior may increase the risk of ovarian cancer, but they do not support a major impact of light and moderate physical activity on ovarian cancer risk.

A prospective study of XRCC1 (X-ray cross-complementing group 1) polymorphisms and breast cancer risk

Introduction

The gene XRCC1 (X-ray repair cross-complementing group 1) encodes a protein involved in DNA base excision repair. Two non-synonymous polymorphisms in XRCC1 (Arg194Trp and Arg399Gln) have been shown to alter DNA repair capacity in some studies in vitro. However, results of previous association studies of these two XRCC1 variants and breast cancer have been inconsistent. We examined the association between polymorphisms in XRCC1 and breast cancer in the American Cancer Society Cancer Prevention Study II (CPS-II) Nutrition Cohort, a large prospective study of cancer incidence in the USA.

Methods

Among the 21,965 women who were cancer-free in 1992 and gave blood between 1998 and 2001, 502 postmenopausal breast cancer cases were diagnosed between 1992 and 2001; 502 controls were matched to cases on age, race/ethnicity, and date of blood collection. Genotyping on DNA extracted from buffy coat was performed with Taqman. Conditional logistic regression was used to examine the association between each polymorphism and breast cancer risk controlling for breast cancer risk factors. We also examined whether factors associated with DNA damage, such as smoking and antioxidant intake, modified the association between XRCC1 polymorphisms and breast cancer.

Results

We observed a significant inverse association between Trp194 carriers (Trp/Trp and Trp/Arg) compared with Trp194 non-carriers in relation to breast cancer (Arg/Arg) (odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95). The inverse association between breast cancer and Trp194 carriers compared with non-carriers was slightly stronger among smokers (OR 0.47, 95% CI 0.24 to 0.94) than never smokers (OR 0.78, 95% CI 0.43 to 1.40). An increased risk associated with the Arg399Gln polymorphism (Gln/Gln versus Arg/Arg) was observed only among women who reported ever smoking cigarettes (OR 2.76, 95% CI 1.36 to 5.63), and not in women who were lifelong non-smokers (OR 0.64, 95% CI 0.33 to 1.26). No other factor examined modified the association between XRCC1 polymorphisms and breast cancer risk.

Conclusion

Our results support the hypothesis that genetic variation in XRCC1, particularly in Arg194Trp, may influence postmenopausal breast cancer risk. In our study, genetic variation in XRCC1 Arg399Gln was associated with breast cancer risk only among women with a history of smoking cigarettes.