Gender differences in trachomatous scarring prevalence in a formerly trachoma hyperendemic district in Tanzania

BACKGROUND

Trachoma is a chronic conjunctivitis caused by the bacterium Chlamydia trachomatis. Repeated infections lead to trachomatous conjunctival scarring which can progress to potentially blinding trachomatous trichiasis (TT). In trachoma hyperendemic conditions, women compared to men have an increased risk of scarring and TT, which can progress to blinding corneal opacification. This study determined if there were gender differences in scarring prevalence and severity when trachoma prevalence approaches elimination, in a formerly trachoma hyperendemic region.

METHODOLOGY/PRINCIPAL FINDINGS

A cross-sectional prevalence study was conducted amongst adults age 15 years and older in Kongwa district, Tanzania in 2019. 3168 persons over age 15 years agreed to be examined and had at least one eye with a gradable image. Ocular photographs were graded for scarring according to a published four-step severity scale. Overall, about half of all study participants had scarring. However, more females (52.3%) had any scarring compared to males (47.2%), OR = 1.22 (95% CI = 1.05-1.43). For every year increase in age, there was a 6.5% increase in the odds of having more severe scarring (95% CI: 5.8%, 7.2%). Women were more likely than men to have severe scarring, OR 2.36 (95% CI: 1.84-3.02). Residence in a community with TF≥10% was associated with a 1.6-fold increased odds of any scarring.

CONCLUSIONS/SIGNIFICANCE

Overall scarring prevalence and more severe scarring prevalence was higher in females compared to males, even adjusting for age and community TF prevalence. The data suggest that processes occur that lead to women preferentially progressing towards more severe scarring compared to men.

Expanding a photographic grading system for trachomatous scarring

BACKGROUND

The purpose was to assess an expansion of a previously published photographic four-step severity grading scale for trachomatous scarring (TS).

METHODS

Images of everted eyelids of adult women in Tanzania were graded for the presence and severity of TS. The previous S3 grade was subdivided into two categories: S3A, one-third to <50% of the upper eyelid conjunctiva scarred; and S3B, 50% to <90%. The reliability and ease of use were evaluated. This new categorisation was then applied to images taken of the same women 5 y prior to evaluate whether it could help detect previously undetected progression.

RESULTS

In total, 142 eyes at baseline and 418 eyes at follow-up after 5 y were graded as S3. Interobserver agreement using the expanded scarring grading scale was a kappa of 0.86. At baseline, 51 (35.9%) eyes were S3A and 91 (64.1%) were S3B. At follow-up after 5 y, 36.6% of the eyes that were previously documented as not having progressed were now detected as having progressed from S3A to S3B. S3B images were more likely to progress to S4 compared with S3A (OR 4.6, 95% CI 2.1 to 9.9).

CONCLUSIONS

Adding S3A and S3B is reliable and detects more scarring progression. It will be beneficial for future studies analysing TS in photographs.

Associated factors of the co-occurrence of trachoma and soil-transmitted helminthiases in children 1 to 9 years old in rural communities of the Amazon basin in Loreto Department, Peru: Results from a population-based survey

BACKGROUND

There is evidence of the occurrence of trachoma in Peru, and studies have shown that soil-transmitted helminthiases (STH) are affecting rural communities in the Amazon basin in Loreto Department. This study was done to estimate trachoma prevalence, STH prevalence, and the associated factors for both diseases in children aged 1-9 years in rural communities of Peru.

METHODOLOGY

A population-based cross-sectional survey was carried out in rural communities of Loreto. A standardized survey questionnaire with individual and household risk factors related to both diseases was used. Ocular examination was done for all participants aged one year and above, and eye swab samples were collected from children with follicular trachoma (TF). Anthropometric measurements, stool samples for STH, and blood samples for hemoglobin measurement were taken from children.

PRINCIPAL FINDINGS

TF prevalence was 7.74% (95% CI 5.08-11.63%), STH prevalence was 49.49% (95% CI 25.00-52.43%), and prevalence of co-occurrence of both diseases was 5.06% (95% CI 2.80-8.98%) in children aged 1-9 years. Being at age 3-8 years old (AOR = 6.76; 95% CI 1.346-33.947), have an unclean face (AOR = 24.64; 95% CI 6.787-89.444), and having been dewormed in the last six months (AOR = 2.47; 95% CI 1.106-5.514), were risk factors of TF. Being a female (AOR = 0.22; 95% CI 0.103-0.457) was associated with decreased odds of TF. Having been dewormed in the last six months (AOR = 0.30; 95% CI 0.139-0.628) was a preventative factor for STH. Risk factors for children with both diseases mirrored the findings for risk factors for individual diseases.

CONCLUSIONS

Neglected tropical diseases and associated risk factors overlap in communities living in vulnerable conditions in the Amazon basin of Peru. These findings support the need to implement integrated interventions, including mass drug administration, water, sanitation, and hygiene for both diseases in the study area.

Risk factors for the progression of trachomatous scarring in a cohort of women in a trachoma low endemic district in Tanzania

Background

Trachoma, a chronic conjunctivitis caused by Chlamydia trachomatis, is the leading infectious cause of blindness worldwide. Trachoma has been targeted for elimination as a public health problem which includes reducing trachomatous inflammation—follicular prevalence in children and reducing trachomatous trichiasis prevalence in adults. The rate of development of trachomatous trichiasis, the potentially blinding late-stage trachoma sequelae, depends on the rate of trachomatous scarring development and progression. Few studies to date have evaluated the progression of trachomatous scarring in communities that have recently transitioned to a low trachomatous inflammation—follicular prevalence.

Methodology/Principal findings

Women aged 15 and older were randomly selected from households in 48 communities within Kongwa district, Tanzania and followed over 3.5 years for this longitudinal study. Trachomatous inflammation—follicular prevalence was 5% at baseline and at follow-up in children aged 1–9 in Kongwa, Tanzania. 1018 women aged 15 and older had trachomatous scarring at baseline and were at risk for trachomatous scarring progression; 691 (68%) completed follow-up assessments. Photographs of the upper tarsal conjunctiva were obtained at baseline and follow-up and graded for trachomatous scarring using a previously published four-step severity scale. The overall cumulative 3.5-year progression rate of scarring was 35.3% (95% CI 31.6–39.1). The odds of TS progression increased with an increase in age in women younger than 50, (OR 1.03, 95% CI 1.01–1.05, p = 0.005) as well as an increase in the household poverty index (OR 1.29, 95% CI 1.13–1.48, p = 0.0002).

Conclusions/Significance

The 3.5-year progression of scarring among women in Kongwa, a formerly hyperendemic now turned hypoendemic district in central Tanzania, was high despite a low active trachoma prevalence. This suggests that the drivers of scarring progression are likely not related to on-going trachoma transmission in this district.

Trachoma, a chronic conjunctivitis caused by Chlamydia trachomatis, presents with follicles (trachomatous inflammation—follicular, TF) in children which leads to trachomatous conjunctival scarring (TS) in young adults. TS can progress to the in-turning of eyelashes, trachomatous trichiasis (TT) which places individuals at high risk of irreversible vision loss. Few studies to date have evaluated the progression of TS in communities that have recently transitioned to a low trachoma prevalence.

We studied the progression of TS in women in Kongwa, Tanzania a district that recently transitioned to a low prevalence of trachoma. We found that the overall cumulative progression of scarring was 35.3% over 3.5 years. The scarring progression rate observed is very similar to what we observed a decade prior in Kongwa when the trachoma prevalence was very high.

Our findings suggest that once scarring has developed it continues to progress irrespective of the current trachoma environment. This has potential ramifications for trachoma elimination efforts. An area could achieve the elimination of TF and still have to deal with scarring progression, which may lead to the development of TT. If this occurs: 1) elimination of TT will be delayed which will delay the overall elimination of trachoma as a public health problem, and 2) the limited resources available to elimination programs may need to be re-allocated.

Patient perceived barriers to surgical follow-up: Study of 6-month post-operative trichiasis surgery follow-up in Tanzania

Background

Post-surgical follow-up is a challenge in low- and middle-income countries. Understanding barriers to trachomatous trichiasis (TT) surgical follow-up can inform program improvements. In this study, patient perceived barriers and enabling factors to follow-up after TT surgery are identified.

Methods

A longitudinal study was carried out in a community-based cohort of persons who received TT surgery in Bahi district, Tanzania. Questionnaires were administered before TT surgery and again after the scheduled 6-month follow-up. Those who did not return were examined at their homes.

Results

At baseline, 852 participants were enrolled. Of these, 633 (74%) returned at 6 months and 128 (15%) did not and were interviewed at home. Prior to surgery, attenders were more likely to report familiarity with a community health worker (CHW) (22% vs. 14%; p = 0.01) and less likely to state that time constraints are a potential reason for failure to follow-up (66% vs. 74%; p = .04). At follow-up, non-attenders were more likely to endorse barriers pertaining to knowledge about the need for follow-up, lack of transportation, and satisfaction with surgery. There was no difference in post-operative TT between attenders and non-attenders (23% vs. 18% respectively; p = 0.25).

Conclusions

The outcome of surgery was not a barrier to follow-up. However, better integration of CHWs into their communities and work at coordinating post-surgical care may improve follow-up rates. Moreover, provision of transportation and implementation of effective reminder systems may address patient-perceived barriers to improve follow-up.

Incidence and progression of trachomatous scarring in a cohort of children in a formerly hyper-endemic district of Tanzania

Background

Trachoma is the leading infectious cause of blindness. Repeated or persistent ocular infection with Chlamydia trachomatis in childhood leads to conjunctival scarring, usually in adulthood but often earlier in areas with greater disease burden. There are limited longitudinal data examining change in scarring in children, especially where trachoma rates are low.

Methodology/Principal findings

A cohort of children, ages 1–9 years, were randomly selected at baseline from 38 communities in Kongwa, Tanzania and followed for 2 years. Rates of trachomatous inflammation—follicular (TF) were <5% over the survey period. At baseline, 1,496 children were recruited and 1,266 (85%) were followed-up. Photographs were obtained at baseline and follow-up and graded for the presence and severity of scarring using a four-point scale ranging between S1-S4. In children without scarring at baseline, 1.6% (20/1,246) were found to have incident scarring, and incident scarring was more common among girls compared to boys. Among children with scarring at baseline, 21% (4/19) demonstrated progression.

Conclusions/Significance

In this formerly hyper-endemic district, the incidence of new scarring in children ages 1–9 years is low, although 21% of those who had scarring at baseline progressed in severity over the 2-year follow-up period. These data provide support for the thesis that while incident scarring more closely reflects ongoing exposure, progression may involve factors independent of ongoing transmission of trachoma.

Trachoma is the leading infectious cause of blindness. The disease is caused by repeated eye infection with the bacterium Chlamydia trachomatis and characterized clinically in its active stage by follicles (TF) and/or severe inflammation (TI). Scarring of the inner surface of the eyelid results from repeated exposure to infection during childhood, and while active trachoma is mostly observed in childhood, scarring and late complications are often only seen in adulthood. In areas with heavy burden of trachoma, scarring may be observed among children, particularly among those with constant, severe trachoma and/or infection. Few studies have examined the incidence and progression of scarring in children in areas where the prevalence of trachoma has been substantially reduced. In this study, we examined the 2-year incidence and progression of scarring in Kongwa district, Tanzania where the prevalence of TF was about 5%. Incidence of new scarring was 0.8%/year and more common among girls. Progression of scarring was 21% in our cohort of children ages 1–9 years. Incidence in children was low in this formerly hyper-endemic area, but a substantial fraction of those with scarring at baseline demonstrated progression over the follow-up period. These data provide support for the thesis that without repeated exposure to trachoma, incident scarring is low, but other mechanisms for progression of scarring apart from ongoing transmission are operating, at least in children.

Photochemical, thermal, biological and long-term degradation of celecoxib in river water. Degradation products and adsorption to sediment

Celecoxib is an anti-inflammatory drug with antibacterial activity whose fate in surface water is unknown. Thus, some assays have been conducted under forced biological, photochemical and thermal conditions, and non-forced conditions, to establish its persistence and degradation products in river water. The results suggest that celecoxib dissolved in river water is not biologically degraded while it is minimally altered after its exposure to sunlight or high temperature (70°C). Only the irradiation at 254nm promotes its complete degradation. Celecoxib is degraded about 3%, in 36 weeks, when water was kept at room temperature and the exposure to sunlight was partially limited as it happens inside a body of water. Residues were monitored by ultra-pressure liquid chromatography/quadrupole time-of-flight/mass spectrometry after solid-phase extraction; eleven degradation products were detected and the structures of nine of them were unequivocally proposed from the molecular formulae and fragmentation observed in high-resolution tandem mass spectra. The long-term transformation products under non-forced conditions were 4-[5-(4-methylphenyl)-3-(trifluoromethyl)-1H-pyrazol-1-yl]benzenesulfonic acid, 4-[1-(4-sulfoaminephenyl)-3-(trifluoromethyl)-1H-pyrazol-5-yl]benzoic acid and a hydroxylated derivative. The degradation over time in presence of sediment was monitored, being slightly higher, about 4%. The adsorption equilibrium constants of celecoxib and degradation products on river sediment were estimated.

Forced and long-term degradation assays of tenoxicam, piroxicam and meloxicam in river water. Degradation products and adsorption to sediment

The fate of the pharmaceutical drugs tenoxicam, piroxicam and meloxicam in river water is evaluated here for first time. So, biological, photochemical and thermal degradation assays have been conducted to estimate their degradation rates and know their degradation products. Results indicated that the direct sunlight irradiation, without any protection, promoted a fast degradation of the oxicams while the chemical reactions in solution were less important. The biological degradation in water was negligible except for tenoxicam in whose case its influence was scarce. When the exposition of river water to sunlight was partially limited and kept under the natural day-night cycle, as occurs inside a body of water, tenoxicam, piroxicam and meloxicam (at 2 μg L^-1) were detected during a period of 15, 27 and 45 days, respectively. Residues were monitored by ultra-pressure liquid chromatography/quadrupole time-of-flight/mass spectrometry after solid-phase extraction and several degradation products were found (10 for tenoxicam, 9 for piroxicam and 7 for meloxicam) and monitored over time. Their structures were proposed from the molecular formulae and fragmentation observed in high-resolution tandem mass spectra; the nature of the transformation products found in the long-term resulted to be very variable for each oxicam. Furthermore, the degradation in presence of river sediment was also monitored over time, with some differences being noted; the adsorption coefficients of the compounds on sediment were calculated, meloxicam exhibited a higher sorption capacity. The ecotoxicity of the different compounds in aquatic ecosystems was predicted, too.

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

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.

Measuring Trachomatous Inflammation-Intense (TI) When Prevalence Is Low Provides Data on Infection With Chlamydia trachomatis

Purpose

Clinical trachoma is the current measure of effectiveness of antibiotic and environmental improvements in trachoma endemic communities. Impact assessments measure only trachomatous inflammation-follicular (TF). Trachomatous inflammation-intense (TI) is not used for decisions on stopping mass drug administration (MDA) or achieving intervention goals. We tested the supposition that TI was not associated with Chlamydia trachomatis when disease prevalence is low.

Methods

In 35 communities undergoing MDA as part of a larger project, 110 children ages 1 to 9 years were randomly selected in each community for surveys at baseline, 6, and 12 months. Both eyelids were graded for TF and TI, and a swab for detection of C. trachomatis infection was taken.

Results

Overall TF prevalence was 5% at baseline. Cases of TI alone constituted 15% of trachoma; 37% of TI cases had infection. At 6 and 12 months, the proportion of trachoma cases that had TI only was 13% and 20%; infection rates were similar to the rates in cases with TF alone.

Conclusions

Despite low prevalence of trachoma, infection rates for TF alone and TI alone were similar at each time point. The exclusion of cases of TI alone when reporting trachoma prevalence discards additional information on infection. Trachomatous inflammation-intense could be considered as part of impact surveys.

Trachomatous Scarring and Infection With Non-Chlamydia Trachomatis Bacteria in Women in Kongwa, Tanzania

Purpose

To assess for an association between conjunctival infection with nonchlamydial bacterial species and the presence of trachomatous scarring (TS) in women in central Tanzania.

Methods

Cross-sectional data were collected from a random sample of women ages 18 and older in 47 trachoma-endemic communities in Kongwa, Tanzania. Each participant completed a survey, provided a conjunctival swab sample, and received an ocular exam to assess for TS. Biologic samples were cultured for bacterial growth and speciation. Contingency tables were used to assess the associations between TS and bacterial carriage.

Results

Complete data was provided by 3882 women (80.7% of invitees). Of all samples, 14% resulted in a positive bacterial isolate. There was no association between TS and nonchlamydial bacterial carriage, whether assessed by species, pathogenicity, or in aggregate. There was a significant association between increasing age and TS severity, but not between age and bacterial carriage. No Corynebacterium was found in the swabs.

Conclusions

This study found no association between TS and nonchlamydial ocular infections, although associations with Corynebacterium cannot be ruled out.

Degradation of indomethacin in river water under stress and non-stress laboratory conditions: degradation products, long-term evolution and adsorption to sediment

The pharmaceutical compound indomethacin is not totally removed in wastewater treatment plants, whose effluents flow into aquatic environments; concentrations in the 0.1-100ng/L range are commonly found in surface waters, and its fate is unknown. Here, biological, photochemical and thermal degradation assays were conducted under stress and non-stress conditions to estimate its degradation rate in river water and establish its degradation products over time. The results revealed that direct sunlight irradiation promoted the complete degradation of indomethacin (2μg/L) in less than 6hr, but indomethacin was detected over a period of 4months when water was kept under the natural day-night cycle and the exposure to sunlight was partially limited, as occurs inside a body of water. The biological degradation in water was negligible, while the hydrolysis at pH7.8 was slow. Residues were monitored by ultra-pressure liquid chromatography/quadrupole time-of-flight/mass spectrometry after solid-phase extraction, and six degradation products were found; their structures were proposed based on the molecular formulae and fragmentation observed in high-resolution tandem mass spectra. 4-Chlorobenzoic and 2-acetamido-5-methoxybenzoic acids were the long-term transformation products, persisting for at least 30weeks in water kept under non-stress conditions. Furthermore, the degradation in the presence of sediment was also monitored over time, with some differences being noted. The adsorption coefficients of indomethacin and degradation products on river sediment were calculated; long-term degradation products did not have significant adsorption to sediment.

Fate of the drug chlorpromazine in river water according to laboratory assays. Identification and evolution over time of degradation products. Sorption to sediment

Toxic effects of the non-biodegradable drug chlorpromazine and its degradation products have been reported on microorganisms in aqueous media. Here, chlorpromazine degradation assays in forced and non-forced conditions have been done to know its persistence and degradation products in river water. Sunlight irradiation promotes the complete degradation of chlorpromazine (2 μg L(-1)) in less than 4 h, but if the exposure to sunlight is limited chlorpromazine is detected during 4 weeks in river water. Sixteen degradation products in surface water are described for first time after solid-phase extraction and analysis by ultra-pressure liquid chromatography/quadrupole time-of-flight/mass spectrometry; their structures are proposed from the molecular formulae of the fragment-ions observed in high-resolution tandem mass spectra. Hydroxylation and oxidation products such as chlorpromazine sulfoxide, 2-hydroxypromazine and 2-hydroxypromazine sulfoxide were predominant degradation products in the early stages; some benzo[1,4]thiazin-6-ol derivatives resulting from the breakdown of the phenothiazine core were the major and relatively stable products after 20 weeks under non-forced conditions. A degradation pathway of chlorpromazine in water is outlined. Moreover, it is shown that chlorpromazine is very strongly adsorbed on sediment while the degradation products that kept the promazine core have a notable capacity of sorption, too; sorption coefficients are calculated. Finally, a prediction about the toxicity of the degradation products in aquatic ecosystems suggests that some of them have toxicities similar, or even higher, than chlorpromazine.

The World Health Organization Recommendations for Trachoma Surveillance, Experience in Nepal and Added Benefit of Testing for Antibodies to Chlamydia trachomatis pgp3 Protein: NESTS Study

BACKGROUND

The World Health Organization (WHO) now requires a second surveillance survey for trachoma after an impact assessment has found follicular trachoma (TF) <5% to determine if re-emergence has occurred. Using new WHO guidelines, we undertook surveillance surveys, and determined the prevalence of infection and antibody positivity, in two districts in Nepal.

METHODS

20 clusters were randomly selected within each district, 15 were randomly selected for antibody testing. In each cluster, we randomly selected 50 children ages 1-9 years and 100 adults ≥15 years. TF and trachomatous trichiasis (TT) were evaluated. Conjunctival swabs to test for chlamydial infection using GenXpert platform were obtained, and dried blood spots were collected to test for antibodies to Chlamydia Trachomatis pgp3 using the Luminex platform.

FINDINGS

3 cases of TF were found in the two districts, and one case of infection. Pgp3 antibody positivity was 2·4% (95% confidence interval: 1·4%, 3·7%), and did not increase with age (P = 0.24). No clustering of antibody positivity within communities was found. TT prevalence was <1/1,000 population.

INTERPRETATION

The surveillance surveys, as proposed by WHO, showed no evidence for re-emergence of trachoma in two districts of Nepal. The low level and no significant increase by age in seroprevalence of antibodies to C trachomatis pgp3 antigen deserve further investigation as a marker of interruption of transmission.

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.

Exposure to an Indoor Cooking Fire and Risk of Trachoma in Children of Kongwa, Tanzania

BACKGROUND

Elimination of blinding trachoma by 2020 can only be achieved if affected areas have effective control programs in place before the target date. Identifying risk factors for active disease that are amenable to intervention is important to successfully design such programs. Previous studies have linked sleeping by a cooking fire to trachoma in children, but not fully explored the mechanism and risks. We propose to determine the risk for active trachoma in children with exposure to cooking fires by severity of trachoma, adjusting for other known risk factors.

METHODS

Complete census of 52 communities in Kongwa, Tanzania, was conducted to collect basic household characteristics and demographic information on each family member. Information on exposure to indoor cooking fires while the mother was cooking and while sleeping for each child was collected. 6656 randomly selected children ages 1-9 yrs were invited to a survey where both eyelids were graded for follicular (TF) and intense trachoma (TI) using the WHO simplified grading scheme. Ocular swab were taken to assess the presence of Chlamydia trachomatis.

FINDINGS

5240 (79%) of the invited children participated in the study. Overall prevalence for trachoma was 6·1%. Odds for trachoma and increased severity were higher in children sleeping without ventilation and a cooking fire in their room (TF OR = 1·81, 1·00-3·27 and TI OR 4·06, 1·96-8·42). Children with TF or TI who were exposed were more likely to have infection than children with TF or TI who were not exposed. There was no increased risk with exposure to a cooking fire while the mother was cooking.

CONCLUSIONS

In addition to known risk factors for trachoma, sleeping by an indoor cooking fire in a room without ventilation was associated with active trachoma and appears to substantially increase the risk of intense inflammation.

Longitudinal relationships among visual acuity, daily functional status, and mortality: the Salisbury Eye Evaluation Study

IMPORTANCE

Determination of the mechanisms by which visual loss increases mortality risk is important for developing interventional strategies.

OBJECTIVE

To evaluate the direct and indirect effects of loss of visual acuity (VA) on mortality risk through functional status changes among aging adults.

DESIGN, SETTING, AND PARTICIPANTS

Prospective longitudinal study of a population-based sample of 2520 noninstitutionalized adults aged 65 to 84 years from September 16, 1993, through July 26, 2003, in the greater Salisbury area of Maryland. Participants underwent reassessment 2, 6, and 8 years after baseline. Mortality status was ascertained from linkage with the National Death Index through 2009.

EXPOSURES

Results of VA testing and self-reported functional status based on activities of daily living (ADL) and instrumental ADL (IADL).

MAIN OUTCOMES AND MEASURE

Mortality.

RESULTS

Worse VA levels at baseline were associated with an increased the risk for mortality (hazard ratio [HR], 1.16 [95% CI, 1.04-1.28]; P < .01) through their effect on lower IADL levels at baseline. Declines in VA over time were associated with increased mortality risk (HR, 1.78 [95% CI, 1.27-2.51]; P < .001) by way of decreasing IADL levels over time. Participants experiencing the mean linear decline in VA of 1 letter on the Early Treatment Diabetic Retinopathy Study acuity chart per year are expected to have a 16% increase in mortality risk during the 8-year study exclusively through associated declines in IADL levels.

CONCLUSIONS AND RELEVANCE

In this longitudinal study of older adults, VA loss adversely affected IADL levels, which subsequently increased the risk for mortality. Prevention of disabling ocular conditions, treatment of correctable visual impairment, and interventions designed to prevent the effect of visual impairment on IADL declines may all reduce mortality risk in aging adults.

The effect of multiple rounds of mass drug administration on the association between ocular Chlamydia trachomatis infection and follicular trachoma in preschool-aged children

Purpose

To examine the relationship between ocular Chlamydia trachomatis infection and follicular trachoma (TF) in children prior to and following multiple rounds of annual mass drug administration (MDA) with azithromycin.

Methodology/principal findings

Thirty-two communities with endemic trachoma in Kongwa District, Tanzania, were offered annual MDA as part of a district-wide trachoma control program. Presence of ocular C. trachomatis infection and TF were assessed in 3,200 randomly sampled children aged five years and younger, who were examined prior to each MDA. Infection was detected using the Amplicor CT/NG assay and TF was identified by clinical examination using the World Health Organization (WHO) simplified grading system. The association between chlamydial infection and TF in children was evaluated at baseline prior to any treatment, and 12 months after each of three annual rounds of mass treatment. Factors associated with infection were examined using generalized estimating equation models.

At baseline, the overall prevalence of chlamydial infection and TF was 22% and 31%, respectively. Among children with clinical signs of TF, the proportion of those with infection was 49% prior to treatment and declined to 30% after three MDAs. The odds of infection positivity among children with clinical signs of TF decreased by 26% (OR 0.74, 95% CI 0.65 to 0.84, p = <0.01) with each MDA, after adjusting for age. For children aged under one year, who did not receive treatment, the relationship was unchanged.

Conclusions/significance

The association between ocular C. trachomatis infection and TF weakened in children with each MDA, as both infection and clinical disease prevalence declined. However, there was still a significant proportion of TF cases with infection after three rounds of MDA. New strategies are needed to assess this residual infection for optimal treatment distribution.

Trachoma, which is caused by infection by the bacterium Chlamydia trachomatis, is the leading preventable cause of blindness worldwide. Annual mass drug administration with azithromycin is recommended for trachoma control; however, monitoring the impact of azithromycin, which targets C. trachomatis, relies on the clinical assessment of follicular trachoma. If the relationship between chlamydial infection and the presence or absence of follicular trachoma were to remain unchanged with each round of treatment, we would be able to predict the level of residual infection, and the need for additional treatment, from the prevalence of follicular trachoma. In this study, we examined the association between infection and presence or absence of follicular trachoma in children prior to and following multiple rounds of treatment. Findings suggest that with increasing rounds of treatment, the prevalence of infection declines in children both with and without signs of follicular trachoma. Newer strategies, including tests that can rapidly detect infection under field conditions, may be needed to assess residual infection in treated communities.

Uncorrected refractive error in a Latino population: proyecto VER

PURPOSE

To determine the prevalence of refractive error (RE), the proportion of those with uncorrected RE, and factors associated with uncorrected RE in Latino adults.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A random sample of 4509 Latinos aged ≥40 years from Arizona with both ophthalmic evaluation and questionnaire.

METHODS

A case of RE was defined as a subject wearing prescription glasses for distance vision whose presenting visual acuity (PVA) was ≥20/25, or a subject with PVA <20/25 in at least 1 eye who improved ≥2 lines after subjective refraction and whose refractive correction met these cutoffs: sphere < -0.5 diopters (D) or >1.0 D or cylinder ≥ +1.0 D. Among those with RE, those who on refraction achieved ≥2 line improvement in at least 1 eye (definition 1) or in both eyes (definition 2) were classified as uncorrected RE. A questionnaire on access to care, acculturation, and socioeconomic variables was used.

MAIN OUTCOME MEASURES

Prevalence of RE and proportion of uncorrected RE.

RESULTS

The prevalence of RE was 64% in at least 1 eye and 51% in both eyes. Of participants with RE in at least 1 eye, 35% have uncorrected RE. Of those with RE in both eyes, 19% have uncorrected RE. Compared with participants with corrected RE, those with uncorrected RE in at least 1 eye were more likely to have lower levels of acculturation (odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.4 per unit decrease) and education (OR 1.6 for ≤6 years vs. >12 years; 95% CI, 1.2-2.2). Uncorrected RE was also associated with not having insurance (OR 1.4; 95% CI, 1.1-1.6), with a low family income (OR 1.4; 95% CI, 1.1-1.7 for <$20,000/year), and with time since last health care visit (OR 1.4; 95% CI, 1.1-1.7 for >1 year vs. <6 months).

CONCLUSIONS

In our sample of Latinos, the proportion of uncorrected RE is high and suggests that one third of those with RE may benefit from new glasses. Indices of marginalization are associated with uncorrected RE and could be targeted for future interventions.

Predictors of lane-change errors in older drivers

OBJECTIVES

To determine the factors that predict errors in executing proper lane changes among older drivers.

DESIGN

Cross-sectional analysis of data from a longitudinal study.

SETTING

Maryland's Eastern Shore.

PARTICIPANTS

One thousand eighty drivers aged 67 to 87 enrolled in the Salisbury Eye Evaluation Driving Study.

MEASUREMENTS

Tests of vision, cognition, health status, and self-reported distress and a driving monitoring system in each participant's car, used to quantify lane-change errors.

RESULTS

In regression models, measures of neither vision nor perceived stress were related to lane-change errors after controlling for age, sex, race, and residence location. In contrast, cognitive variables, specifically performance on the Brief Test of Attention and the Beery-Buktenicka Test of Visual-Motor Integration, were related to lane-change errors.

CONCLUSION

The current findings underscore the importance of specific cognitive skills, particularly auditory attention and visual perception, in the execution of driving maneuvers in older individuals.

Constant ocular infection with Chlamydia trachomatis predicts risk of scarring in children in Tanzania

OBJECTIVE

Clinically, constant severe trachoma predicts an increased risk of scarring in children. There are no data on the risk of scarring associated with constant infection with Chlamydia trachomatis, regardless of clinical manifestation. We propose to determine the 5-year incidence of scarring in children with a history of constant severe trachoma, constant infection, or both compared with children who had a history of neither.

DESIGN

A 5-year, longitudinal observational study.

PARTICIPANTS

Children aged less than 10 years with data on trachoma and infection for 3 of the 5 visits in the first 18 months, and follow-up 5-year data on scarring.

METHODS

Data were collected on clinical trachoma, and ocular swabs were taken to determine the presence of C. trachomatis in children in a hyperendemic village in Tanzania. Images were graded for scarring. Data were collected at baseline; 2, 6, 12, and 18 months; and 5 years from baseline. Severe trachoma was defined as the presence of 10 or more follicles, or trachoma intense. A child had constant infection (severe trachoma) if infection (severe trachoma) was present on at least 3 visits before the 5-year survey.

MAIN OUTCOME MEASURES

Five-year risk of scarring.

RESULTS

Of the 189 children, 22 (11.6%) had constant severe trachoma, but not constant infection. Nine children (4.8%) had constant infection but not constant severe trachoma. Both constant severe trachoma and constant infection were present in 16 children (8.5%). The 5-year incidence of scarring was similar in all 3 groups; children with constant severe trachoma only, with constant infection only, and with both were most likely to develop scars (35.0%, 44.4%, 31.2%, respectively) compared with those with sporadic trachoma or infection (15.2%) or neither (6.8%) (P = 0.0002).

CONCLUSIONS

Children with constant infection are also likely to have constant severe trachoma, and their 5-year risk of scarring is high compared with children with sporadic severe trachoma or infection. These data further support the presence of a subgroup of children who cannot clear infection with C. trachomatis, who may manifest a severe immunologic response to infection, and who are at increased risk of scarring sequelae.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

The hepatocellular thyroid status of uremic rats estimated from the abundances of thyroid hormone-dependent nucleoplasmic proteins

Although the serum thyroxine (T4) and triiodothyronine (T3) concentrations of uremic rats are commensurate with moderate hypothyroidism, their thyroid status at the tissue level remains controversial. To help establish the hepatocellular thyroid status of uremic rats, a novel tissue marker (nuclear protein abundances) was evaluated in uremic rats (U), hypothyroid rats (H), and hypothyroid uremic rats (HU). Uremia was established by five-sixths nephrectomy. Moderate hypothyroidism was established by partial thyroidectomy or by provision of drinking water supplemented with propylthiouracil and T4. Normal rats (N) and pair-fed, sham-operated rats (1 to 3 weeks after surgery) served as controls. Animals were killed 1 to 5 weeks postoperatively. The following values were obtained 5 weeks after surgery, at which time the total and free serum T4 and T3 levels of the hypothyroid rats (H) were equivalent to those of the uremic rats (U). Total T4 (micrograms/dL +/- 1 SD): N, 5.4 +/- 1.7; H, 2.2 +/- 0.5; U, 1.9 +/- 1.5; HU, 0.5 +/- 0.0. Free T4 (ng/dL +/- 1 SD): N, 535 +/- 165; H, 126 +/- 37; U, 135 +/- 89; HU, 26 +/- 1. Total T3 (ng/dL +/- 1 SD): N, 63 +/- 20; H, 39 +/- 14; U, 38 +/- 18; HU, 13 +/- 4. Free T3 (ng/dL +/- 1 SD): N, 7.83 +/- 3.00; H, 3.87 +/- 1.05; U, 3.47 +/- 1.73; HU, 0.94 +/- 0.47. Hepatocellular thyroid status was estimated from the relative abundances of two nucleoplasmic proteins on polyacrylamide gel electrophoregrams.(ABSTRACT TRUNCATED AT 250 WORDS)

Tissue-specific differences in the compartmentalization of rat nuclear triiodothyronine receptors

In addition to the recognized rat liver nuclear T3 receptor extractable with hypertonic salt, recent studies have described nucleoplasmic receptors extractable with isotonic KCl and salt-resistant receptors localized to the nuclear matrix. A method was developed for the determination of intra-nuclear receptor distribution in small samples of nuclei dispersed within glass wool matrices. After in vitro labelling with 6 nmol/l [125I]T3, dispersed nuclei were sequentially extracted with 0.15 mol/l KCl (yielding nucleoplasmic receptors), 0.4 mol/l KCl. and 2 mol/l KCl (the latter two concentrations yielding hypertonic salt-extractable receptors). The salt-resistant receptors were retained within the glass wool columns. The intra-nuclear distribution of in vivo labelled receptors was very similar to that obtained by in vitro labelling. The equilibrium association constants for L-T3 binding among the receptor pools ranged from 0.6 X 10(9) to 1.0 X 10(9) l/mol. The distribution of total nuclear receptors within each nuclear compartment was (percentage of nucleoplasmic, hypertonic salt-extractable, and salt-resistant receptors): Cerebrum: 23.6, 52.2, 24.2; Liver: 25.2, 57.2, 17.5; Kidney: 45.9, 33.5, 20.6; Testis: 65.5, 14.7, 19.7; and Spleen: 66.7, 18.7, 14.6. The rank order of percentage of hypertonic salt-extractable receptors approximates the rank order of thyroid hormone-responsiveness by traditional criteria. The inverse is true for the percentage of nucleoplasmic receptors. The percentage of salt-resistant receptors was very similar in all of the tissues.

Lack of evidence for aspirin use and prevention of cataracts

A population-based cross-sectional survey of 838 men aged 30 years and over was conducted to examine the effect of aspirin, and other potential risk factors, on the prevalence of cataracts. Lens opacities were graded on clinical examination for location (cortical, nuclear, and posterior or subcapsular) and severity. The results do not support the claim that large doses of aspirin, or frequent use of aspirin, protects against or retards the growth of lens opacities.