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Agreement between novice and experienced trachoma graders improves after a single day of didactic training
  1. Bidya P Prasad1,
  2. Ramesh C Bhatta1,
  3. JSP Chaudhary1,
  4. Shekhar Sharma2,
  5. Sailesh Mishra2,
  6. Puja A Cuddapah3,
  7. Nicole E Stoller3,
  8. Sun N Yu3,
  9. Salman A Rahman3,
  10. Michael Deiner4,
  11. Jeremy D Keenan3,4,
  12. Bruce D Gaynor3,4
  1. 1Geta Eye Hospital, Geta, Dhangadhi, Nepal
  2. 2National Trachoma Program, Nepal Netra Jyoti Sangh, Tripureswor, Kathmandu, Nepal
  3. 3F.I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
  4. 4Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr Bruce D Gaynor, F.I. Proctor Foundation, Department of Ophthalmology, University of California San Francisco, 513 Parnassus, Med Sci 334C, San Francisco, CA 94143-0944, USA; bruce.gaynor{at}


Background/aims Prevalence estimates and treatment decisions for trachoma are based entirely on ocular clinical examination. The aim of the current study is to demonstrate that ophthalmic assistants can be trained and certified to provide trachoma grading within a single day.

Methods Conjunctival photographs from an area with endemic trachoma were randomised into two sets of 60 cases. Photographs were graded for trachomatous inflammation—follicular (TF) and trachomatous inflammation—intense (TI) by three experienced graders. Inter-rater reliability of eight ophthalmic assistants and three experienced graders were compared before and after training.

Results The mean κ agreement between the ophthalmic assistants and the consensus grades of the experienced graders for TF was 0.38 (95% CI 0.18 to 0.58) before training, and increased to 0.60 (95% CI 0.42 to 0.78) after training (p=0.07). The mean κ agreement for TI was 0.16 (95% CI 0.02 to 0.30) before training, and increased to 0.39 (95% CI 0.20 to 0.58) after training (p=0.02).

Conclusion A single day of training improves agreement between prospective and experienced trachoma graders, and provides the basis for certification of workers who are able to accurately grade trachoma and generate reliable prevalence estimates.

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