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.

Prevalence of trachoma in the area councils of the Federal Capital Territory, Nigeria: results of six population-based surveys.

PURPOSE: The World Health Organization's (WHO's) global trachoma elimination programme recommends mapping of trachoma at district level for planning of elimination activities in affected populations. This study aimed to provide data on trachoma prevalence for the Area Councils of Nigeria's Federal Capital Territory (FCT). METHODS: Using the Global Trachoma Mapping Project (GTMP) protocols, in March and April 2014, we conducted a population-based cross-sectional survey in each of the six Area Councils of FCT. Signs were defined based on the WHO simplified grading scheme. RESULTS: 98% to 100% of the targeted households were enrolled in each Area Council. The number of children aged 1-9 years examined per Area Council ranged from 867 to 1248. The number of persons aged ≥15 years examined ranged from 1302 to 1836. The age-adjusted prevalence of trachomatous inflammation-follicular in 1-9-year-olds was <5% in each Area Council. The age- and gender-adjusted prevalence of trichiasis in those aged ≥15 years ranged from 0.0% to 0.3%; two Area Councils (Gwagwalada and Kwali) had prevalences above the 0.2% elimination threshold. The proportion of households with access to improved latrines and water sources ranged from 17 to 90% and 39 to 85% respectively. CONCLUSIONS: Gwagwalada and Kwali Area Councils need to perform more trichiasis surgeries to attain the trichiasis elimination prevalence target of 0.2% in persons aged ≥15 years. No Area Council requires mass antibiotic administration for the purposes of trachoma's elimination as a public health problem. All Area Councils need to accelerate provision of access to improved water sources and latrine facilities, to achieve universal coverage.

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 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.

Prevalence of Trachoma in Niger State, North Central Nigeria: Results of 25 Population-Based Prevalence Surveys Carried Out with the Global Trachoma Mapping Project.

PURPOSE: To determine the prevalence of trachoma in each of the 25 local government areas (LGAs) of Niger State, Nigeria. METHODS: A population-based cross-sectional survey was conducted in each Niger State LGA between March and April 2014, as part of the Global Trachoma Mapping Project (GTMP). GTMP protocols were used in planning and conduct of the surveys. Using probability proportional to size, 25 clusters were selected; in each of these clusters, 25 households were enrolled for the survey. All residents aged 1 year and older were examined by GTMP-certified graders for trachomatous inflammation - follicular (TF) and trichiasis using the World Health Organization simplified grading scheme. Additionally, we collected data on household water and sanitation facilities. RESULTS: Only one LGA (Kontagora) had TF prevalence in 1-9-year-olds above 10%; one other LGA (Rafi) had TF prevalence between 5.0 and 9.9%. Six LGAs need trichiasis surgical services provided to achieve a prevalence of <1 case of trichiasis per 1000 total population. The proportion of households with access to improved water sources ranged from 23 to 100%, while household-level access to improved latrines ranged from 8 to 100% across the LGAs. CONCLUSION: The prevalence of trachoma is relatively low in most of Niger State. There is a need for community-based trichiasis surgical services in a small number of LGAs. The trachoma elimination program could engage water and sanitation agencies to augment access to improved water and sanitation facilities, for human rights reasons. Kontagora and Rafi need community-based interventions to reduce the prevalence of active trachoma.

Prevalence of Trachoma in Katsina State, Nigeria: Results of 34 District-Level Surveys.

PURPOSE: To determine the local government area (LGA)-level prevalence of trachoma in all 34 LGAs of Katsina State. METHODS: A population-based prevalence survey was conducted in each LGA of Katsina State, using the Global Trachoma Mapping Project methodology. We used a 3-stage cluster random sampling strategy to select 25 households from each of 25 clusters. We examined all residents of selected households aged 1 year and older for the clinical signs of trachomatous inflammation-follicular (TF), trachomatous inflammation-intense and trichiasis, using the World Health Organization (WHO) simplified grading scheme. RESULTS: We examined 129,281 persons. Six LGAs had a TF prevalence ≥10%, and another six LGAs had a TF prevalence between 5% and 9.9%; all 12 require mass drug administration with azithromycin plus other interventions. The prevalence of trichiasis was ≥1.0% in 13 LGAs, and there is a need to perform trichiasis surgery in over 26,000 persons to reach targets set by the WHO for elimination of trichiasis. CONCLUSION: The prevalence of TF is generally low in Katsina state, but urgent steps must be taken to implement the full SAFE strategy (surgery, antibiotics, facial cleanliness, environmental improvement) in at least 12 LGAs while also stepping up efforts to provide community-based trichiasis surgery throughout the whole state, in order to make trachoma elimination by 2020 a reality.

Trachoma Mapping in Gombe State, Nigeria: Results of 11 Local Government Area Surveys.

PURPOSE: To determine the need or otherwise for establishment of a trachoma elimination program in Gombe State, Nigeria, by estimating the population-based prevalence of trachoma in each Local Government Area (LGA) of Gombe. METHODS: Using a multi-stage, systematic, random, and quasi-random sampling approach and Global Trachoma Mapping Project support, we selected 25 clusters in each LGA. In each cluster, we selected 25 households and all consenting residents aged 1 year and older were examined for trachomatous inflammation-follicular (TF) and trichiasis, using the World Health Organization simplified grading scheme. RESULTS: No LGA in Gombe State had a TF prevalence ≥5% in 1-9-year-olds. All LGAs had trichiasis prevalences above the elimination threshold and should be targeted for community-based delivery of trichiasis surgery. Only three LGAs had household-level improved wash water access of greater than 80%. Access to improved sanitation facilities was also poor as household access to improved sanitation facilities was above 80% in only one LGA. CONCLUSION: A trachoma program focused on delivery of trichiasis surgery is required in Gombe. Improvements in water and sanitation, through engagement with other sectors, are necessary.