BackgroundAs highly trachoma-endemic countries approach elimination, some districts will have prevalences of trachomatous inflammation–follicular in 1–9-year-olds (TF1-9) of 5.0–9.9%. The World Health Organization (WHO) previously recommended that in such districts, TF prevalence be assessed in each sub-district (groupings of at least three villages), with three rounds of azithromycin treatment offered to any sub-district in which TF≥10%. Given the large number of endemic districts worldwide and the human and financial resources required to conduct surveys, this recommendation may not be practical. In a group of 8 Malawi districts with baseline TF prevalences of 5.0–9.9%, the Malawi Ministry of Health administered one round of azithromycin mass treatment, to the whole of each district, achieving mean coverage of ~80%. Here, we report impact surveys conducted after that treatment.MethodsWe undertook population-based trachoma surveys in 18 evaluation units of the 8 treated districts, at least 6 months after the MDA. The standardized training package and survey methodologies of Tropical Data, which conform to WHO recommendations, were used.ResultsEach of the 18 evaluation units had a TF1-9 prevalence <5.0%.ConclusionThe study demonstrates that in Malawi districts with TF of 5.0–9.9%, one round of azithromycin MDA with ~80% coverage associates with a reduction in TF prevalence to <5%. Further evidence for this approach should be collected elsewhere.

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.