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PURPOSE To determine the 5-year incidence rate of scarring, and associated factors, in the population of Maindi, Tanzania. METHODS A census of every resident was obtained at baseline, and ocular examinations for the presence and severity of trachoma were performed. Images of the upper eyelid were taken and graded for the presence and severity of scarring, according to a four-step severity scale based on photographs. Five years after baseline, a second series of images was taken and graded for scarring. Incident scarring was defined as new scars in those without scarring at baseline; progression was defined as those with scars that worsened by one step or more at 5 years. RESULTS The rate of scarring at baseline increased with age, from 1% in the < 6-year to 38% in the 41 +-year age group. Females at any age had more scarring than did males. The 5-year incidence rate of scarring was 0.20 (95% confidence interval [CI], 0.16–0.25), but varied with age up to 0.43 in the 41 +-year group. There was a striking cohort effect, with those aged less than 16 years at baseline having more prevalent scarring and incidence rates comparable to those aged 16 to 40. Progression rates averaged 0.47 (95% CI, 0.36–0.58). CONCLUSIONS In this trachoma-endemic community, incident scarring was high, especially in the younger cohorts. A dramatic increase in risk of trachomatous scarring occurred approximately 15 years ago and appears to be unabated. Trachoma control programs to reduce risk of scarring are urgently needed to avoid blinding complications in this community.

Introduction: Ocular Chlamydia trachomatis infection, the causative agent for trachoma, is responsible for 1.9 million cases of visual loss world-wide. Mass Drug Administration (MDA) with azithromycin to entire trachoma-endemic districts is part of the World Health Organization's public health strategy for trachoma elimination.Areas covered: Background on C. trachomatis and the epidemiology of trachoma are presented, followed by a review of the antibiotics for treatment and the need for a public health approach to trachoma elimination. The effectiveness of mass drug administration is presented, concluding with challenges to trachoma elimination in the future. Expert opinion: MDA using azithromycin is a key component of the public health strategy for trachoma elimination. With high coverage in children, there is good evidence that MDA drops the community pool of infection. There are challenges to trachoma elimination by the year 2020, and the drug donation program for country MDAs will be integral to ongoing efforts