The burden of trachoma in the rural Nile Delta of Egypt: a survey of Menofiya governorate

Gender differences in the surgical management of trachomatous trichiasis: an exploratory analysis of global trachoma survey data, 2015-2019

BACKGROUND

Trachomatous trichiasis (TT) is a painful, potentially blinding eye condition that can be managed through epilation or surgery. Women are affected by TT approximately twice as often as men and are believed to face gendered barriers to receiving surgical care to prevent vision loss.

METHODS

We used data from 817 cross-sectional surveys conducted during 2015-2019 in 20 African countries to estimate the prevalence difference (PD) between female and male eyes for four outcomes potentially indicating gender-related differences in TT management: (1) received surgery and developed postoperative TT (PTT), (2) never offered surgery, (3) offered surgery but declined it, and (4) offered epilation but never offered surgery.

RESULTS

The prevalence was modestly elevated among female eyes compared with male eyes for having PTT (PD:1.8 [95% confidence limits (CL): 0.6, 3.0]) and having declined surgery for the eye (PD: 6.2 [95% CL: 1.8, 10.7]). The proportion offered epilation was similar by gender (PD:0.5 [95% CL: -0.4, 1.3]), while never having been offered surgery was somewhat more prevalent among male eyes (PD: -2.1 [95% CL: -3.5, -0.7]).

CONCLUSIONS

Our results suggest potential gender differences in TT management. More research is needed to determine the causes and implications of the observed differences.

Modified Anterior Lamellar Recession for All Grades of Upper Eyelid Trachomatous Cicatricial Entropion

Purpose

This study aims to assess the combination of anterior lamellar recession (ALR) with blepharoplasty, suprasternal fixation, and internal eyelash bulb extirpation of aberrant lashes posteriorly located in patients with any grade of upper eyelid trachomatous cicatricial entropion.

Patients and Methods

We reviewed the clinical data of eighty-six patients (143 eyelids) including age, gender, systemic medical illnesses, and comprehensive ophthalmological assessment. Eyelid evaluation was recorded, including laterality, previous surgical technique used, possible trichiasis etiology, abnormality of the lid margin, tarsal plate consistency (shrinkage or loosening), skin fold overhanging, laxity of the pretarsal skin, margin reflex distance 1 (MRD1), lagophthalmos, and lid retraction. The success rate was assessed at 3, 6, 9, and 12 months postoperative.

Results

The success rate was 97.2% in the third month, which decreased significantly to 92.3% in the 6th month and 90.2% in the 9th month (P = 0.01, and 0.001 respectively). In the 9th month, we had fourteen failed cases. All of them were submitted for a second intervention. Three underwent electrolysis, four cases underwent re-internal bulb extirpation, four cases underwent the same procedure, and three cases underwent epilation. The success of the failed cases after the second intervention was significantly associated with the type of reintervention (P = 0.03), in which all of them succeed except two cases that underwent epilation. Kaplan-Meier analysis showed that the mean recurrence time in our study was 6.8 months (95% CI = 5.8-7.7 months).

Conclusion

This study showed the combination of ALR with blepharoplasty, suprasternal fixation, and cauterization or internal bulb extirpation of posteriorly located lashes procedure resulted in a high success rate in patients with any form of UCE with no increase in incidence or degree of lagophthalmos associated with UCE.

Time trends and heterogeneity in the disease burden of trachoma, 1990-2019: a global analysis

PURPOSE

To evaluate the epidemiological trends and associated risk factors of disease burden due to trachoma.

METHODS

Data for the country-specific disability-adjusted life year (DALY) number, rate and age-standardised rate of trachoma together with related data of other common eye diseases were acquired from the Global Burden of Disease Study 2019 database. The Socio-Demographic Index (SDI), Human Development Index (HDI), inequality-adjusted HDI and other related indices were obtained from published data or publicly available databases. Regression analyses were conducted to evaluate the associations between potential risk factors and the age-standardised DALY burden of trachoma.

RESULTS

The global DALY burden due to trachoma decreased by 37% from 1990 to 2019 and decreased by 69.8% after adjusting for age and population growth, and, in available 1990-2019 data, had the greatest reduction in attributable DALYs of all common eye disease, with the others analysed being cataract, glaucoma, refractive disorders and age-related macular degeneration. Women had higher age-standardised DALY burden due to trachoma than men (p<0.001). The African region (p<0.001) had the heaviest burden among global regions. The age-standardised DALY rate was higher in countries with lower income (p<0.001) and lower SDI (p<0.001). Higher disease burden due to trachoma was associated with lower HDI (β=-48.102, 95% CI -86.888 to -9.316, p=0.016), lower SDI (β=-48.063, 95% CI -83.702 to -12.423, p<0.001) and lower expected years of schooling (β=-2.352, 95% CI -3.756 to -0.948, p=0.002).

CONCLUSIONS

The global disease burden due to trachoma decreased from 1990 to 2019 and it had the greatest reduction compared with other common eye diseases. Lower HDI, socioeconomic status and educational level were related to a higher national disease burden of trachoma. Our findings could provide necessary information for trachoma control and prevention.

Perceptions of ophthalmologists on the impact of trachoma in Egypt: a mixed-methods, nationwide survey

PURPOSE

Understanding the perception and practices of ophthalmologists for trachoma is important to develop interventions aimed at disease elimination in Egypt. The survey investigated: (1) the views and practice patterns of Egyptian ophthalmologists for trachoma and (2) the influence of geographic location, setting, and years of practice on ophthalmologists' perceptions.

METHODS

A questionnaire sent to ophthalmologists currently working in Egypt collected information on: (1) demographics, (2) caseload and practice patterns for trachoma, (3) 13 Likert scale questions regarding the current state of trachoma, and (4) two open-ended written response questions.

RESULTS

Of the 500 recipients, 194 ophthalmologists participated. 98% of the respondents reported seeing trachoma patients in their practice. 28.8% agreed that trachoma is currently an active health problem in Egypt, with ophthalmologists in public practice having significantly higher agreement scores compared to private practitioners (p = 0.030). Rural ophthalmologists were significantly more likely to agree that a targeted trachoma control program is needed in their location of practice compared to their urban counterparts (p < 0.001). Open-ended questions revealed recurrent themes, including the rural distribution of trachoma patients and the high volume of patients with corneal opacity.

CONCLUSION

Ophthalmologists' experiences with trachoma in Egypt differed based on practice setting, years in practice, and location, and the overall perception of the impact of the disease remains low. However, there was widespread agreement that trachoma is present in communities across the country. Practitioners in rural areas and in the public sector shared a disproportionate burden of the trachoma caseload. The perspectives of such ophthalmologists must be emphasized in decision-making related to trachoma interventions.

Population-based rapid assessment of avoidable blindness survey in Sohag governorate in Egypt

OBJECTIVES

To determine the prevalence and causes of blindness and vision impairment, and the coverage and quality of cataract surgical services, among population aged 50 years and older in Sohag governorate in Egypt.

DESIGN

A population-based cross-sectional survey using two-stage cluster random sampling following the rapid assessment of avoidable blindness methodology.

SETTING

A community-based survey conducted by six teams of ophthalmologists, assistants and local guides. Enrolment and examination were door-to-door in selected clusters.

PARTICIPANTS

Using 2016 census data, 68 population units were randomly selected as clusters (of 60 people) with probability proportionate to population size. Anyone aged 50 years and older, residing in a non-institutional setting in a cluster for at least 6 months, was eligible to participate.

PRIMARY AND SECONDARY OUTCOME MEASURES

The prevalence and causes of blindness and vision impairment. Secondary outcomes were CSC and effectiveness and participant-reported barriers to cataract surgery.

RESULTS

Of 4078 participants enrolled, 4033 (98.9%) were examined. The age-adjusted and sex-adjusted prevalence of blindness, severe vision impairment and moderate vision impairment were 5.9% (95% CI 4.8% to 6.9%), 4.7% (95% CI 3.8% to 5.7%) and 18.9% (95% CI 16.8% to 21.0%), respectively. Cataract caused most of blindness (41.6%), followed by non-trachomatous corneal opacity (15.7%) and posterior segment diseases (14.5%). Cataract surgical coverage (CSC) for persons for visual acuity <3/60 was 86.8%, the proportion of cataract surgeries with poor visual outcome was 29.5% and effective CSC (eCSC) was 44.9%. eCSC was lower in women than men. The most frequently reported barrier to surgery was cost (51.5%).

CONCLUSIONS

The prevalence of blindness in Sohag governorate is higher than districts in other middle-income countries in the region. CSC was high; however, women suffer worse quality-corrected CSC than men. The quality of cataract surgery needs to be addressed, while health system strengthening across government and private settings could alleviate financial barriers.

Prevalence of trachoma in four marakez of Elmenia and Bani Suef Governorates, Egypt

PURPOSE

In 2015, to determine where interventions are needed to eliminate trachoma as a public health problem from Egypt, we initiated population-based prevalence surveys using the Global Trachoma Mapping Project platform in four suspected-endemic marakez (districts; singular: markaz) of the governorates of Elmenia and Bani Suef.

METHODS

In each markaz, 30 households were selected in each of 25 villages. Certified graders examined a total of 3682 children aged 1-9 years in 2993 households, noting the presence or absence of trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense (TI) in each eye. A total of 5582 adults aged ≥15 years living in the same households were examined for trachomatous trichiasis (TT). Household-level access to water and sanitation was recorded.

RESULTS

Three of four marakez had age-adjusted TF prevalence estimates in 1-9-year olds of >10%; the other markaz had a TF prevalence estimate of 5-9.9%. Estimates of the age- and gender-adjusted prevalence of unmanaged TT in adults ranged from 0.7% to 2.3%. Household-level access to water and sanitation was high. (We did not, however, measure use of water or sanitation facilities.) Conclusions: Each of the four marakez surveyed has trachoma as a public health problem, with a need for implementation of the SAFE (surgery, antibiotics, facial cleanliness, environmental improvement) strategy. Further mapping is also required to determine the need for interventions in other areas of Egypt.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Prevalence and determinants of active trachoma among preschool-aged children in Dembia District, Northwest Ethiopia

Background

Trachoma is an infectious eye disease caused by Chlamydia trachomatis, which is the leading infectious cause of blindness worldwide. In areas where trachoma is endemic, active trachoma is common among preschool-aged children, with varying magnitude. This study aimed to estimate the prevalence of active trachoma and associated risk factors among preschool-aged children in Dembia District, northwest Ethiopia.

Methods

A community-based cross-sectional survey was conducted among preschool-aged children of northwest Ethiopia. Multistage systematic random sampling was used to select 695 subjects. Trained clinical optometrists subjected each child to an ocular examination and assessed the presence of active trachoma. Face to face interview using pretested and structured questionnaire were conducted to collect data on possible risk factors. Trachoma cases were graded following a World Health Organization simplified grading scheme. All statistical analysis was carried out using the SPSS software version 20. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used to identify factors associated with active trachoma.

Results

Of the 681 preschool-aged children studied, 18% (95% CI: 15.4% – 21.1%) had a prevalence of active trachoma. Children who had clean faces (absence of nasal and ocular discharges) had a lower chance of having active trachoma [aOR = 0.55, 95% CI: 0.37 – 0.82]. The odds of having active trachoma decreased with an increase in the distance to a water point [aOR = 0.51, 95% CI: 0.33 – 0.78]. Similarly, no or poor utilization of liquid waste disposal in the child’s household was associated with an increased chance of having active trachoma [aOR = 3.83, 95% CI: 1.26 – 11.61].

Conclusion

The prevalence of active trachoma in these preschool-aged children was found to be high and needs special interventions that focus on educating families about proper face washing, liquid waste disposal, and improving safe water supply near the households.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0345-8) contains supplementary material, which is available to authorized users.

Identifying Patient Perceived Barriers to Trichiasis Surgery in Kongwa District, Tanzania

BACKGROUND

Trachomatous trichiasis (TT), inturned eyelashes from repeated infection with Chlamydia trachomatis, is the leading infectious cause of blindness in the world. Though surgery will correct entropion caused by trachoma, uptake of TT surgery remains low. In this case-control study, we identify barriers that prevent TT patients from receiving sight-saving surgery.

METHODOLOGY/PRINCIPAL FINDINGS

Participants were selected from a database of TT cases who did (acceptors) and did not (non-acceptors) have surgery as of August 2015. We developed an in-home interview questionnaire, using open and closed-ended questions on perceived barriers to accessing surgical services. We compared responses between the acceptors and non-acceptors, examining differences in reasons for and against surgery, sources of TT information, and suggestions for improving surgical delivery. 167 participants (mean age 61 years, 79.7% females) were interviewed. Compared to acceptors, non-acceptors were more likely to report they had no one to accompany them to surgery (75.3% vs. 42.6%, p<0.0001), they could manage TT on their own (69.9% vs. 31.5%, p<0.0001), and the surgery camp was too far (53.4% vs. 28.7%, p = 0.001). Over 90% of both acceptors and non-acceptors agreed on the benefits of having surgery. Fear of surgery was the biggest barrier stated by both groups. Despite this fear, acceptors were more likely than non-acceptors to also report fear of losing further vision without surgery.

CONCLUSIONS/SIGNIFICANCE

Barriers included access issues, familial and/or work responsibilities, the perception that self-management was sufficient, and lack of education about surgery. Fear of surgery was the biggest barrier facing both acceptors and non-acceptors. Increasing uptake will require addressing how surgery is presented to community residents, including outlining treatment logistics, surgical outcomes, and stressing the risk of vision loss.

Prevalence of Trachoma in Jigawa State, Northwestern Nigeria

PURPOSE

To determine the magnitude of trachoma and the prevalent forms of the disease, and to provide baseline data for the establishment of a trachoma control program in Jigawa State, northwestern Nigeria.

METHODS

A population-based cross-sectional survey was conducted in Jigawa State in May 2007 using a 2-stage cluster random sampling technique to select 4598 persons from 40 villages based on probability proportional to size. All participants were examined using a penlight and a 2.5 × binocular loupe for signs of trachoma, and graded using the World Health Organization (WHO) simplified grading system.

RESULTS

A total of 4598 people were seen with 99.96% coverage. Of these, 2460 (53.5%) were female and 2138 (46.5%) were male. Mean age was 21.6 years ( ± 19.8 years). The prevalence of follicular trachoma in children aged ≤9 years was 20.5% (95% confidence interval, CI, 18.7-22.4%) with no difference between the sexes. The prevalence of trichiasis in adults aged ≥15 years was 5%, and the prevalence was higher in females than males (odds ratio 2.60, 95% CI 2.06-3.28; p < 0.001).

CONCLUSION

Trachoma is a major problem in Jigawa State; there is a need to train trichiasis surgeons and empower them to carry out community-based surgery. District-level prevalence of trachoma needs to be determined to know which aspects of the WHO SAFE strategy (surgery, antibiotics, facial cleanliness and environmental improvements) need to be emphasized in each district.

A Community-based Eye Care Intervention in Southern Egypt: Impact on Trachomatous Trichiasis Surgical Coverage

Purpose:

The purpose of this study was to measure the impact of a community-based intervention on uptake of trichiasis surgery in Southern Egypt.

Methods:

Four villages where trachoma is endemic were randomly selected in the Samalout district, Egypt. Two villages were selected for intervention (intervention villages) and two matched villages for nonintervention (nonintervention villages). The intervention model provided community information sessions, door-to-door health education, screening, and improvements in the clinical capacity of eye care providers. The intervention was evaluated through two pre- and post-intervention community-based surveys that included the prevalence of trachoma and the utilization of eye care services at local hospitals. All patients with trichiasis answered a questionnaire regarding surgical utilization and barriers.

Results:

In the baseline survey, the trachomatous trichiasis (TT) surgical coverage was 22.7% (38.9% males, 16.7% females) in all villages. Following the intervention, the TT surgical coverage increased to 68% in villages that received the intervention (81.5% males, 60% females). Nonintervention villages had a TT surgical coverage of 26.1% (37.5% males, 20% females). In the intervention villages, the prevalence of TT significantly decreased from 9.4% (5.7% males, 11.8% females) to 3.8% (1.9% males, 5.1% females) (P = 0.013), in 2008. In nonintervention villages, there was a slight, but insignificant decrease in TT from 10.1% (3.1% males, 14.4% females) to 8.2% (3% males, 11.5% females) (P = 0.580). The major barriers to uptake of TT surgical services were: “Feeling no problem” (17.3%), “fear of surgery” (12.7%) and “cost” (12.7%).

Conclusion:

A community-based eye health education program with door-to-door screening significantly increased the uptake of TT surgical services. Although improvements to the delivery of surgical service are essential, they did not lead to any significant improvements in the nonintervention villages.

Trachoma

Trachoma is the most common infectious cause of blindness. Repeated episodes of infection with Chlamydia trachomatis in childhood lead to severe conjunctival inflammation, scarring, and potentially blinding inturned eyelashes (trichiasis or entropion) in later life. Trachoma occurs in resource-poor areas with inadequate hygiene, where children with unclean faces share infected ocular secretions. Much has been learnt about the epidemiology and pathophysiology of trachoma. Integrated control programmes are implementing the SAFE Strategy: surgery for trichiasis, mass distribution of antibiotics, promotion of facial cleanliness, and environmental improvement. This strategy has successfully eliminated trachoma in several countries and global efforts are underway to eliminate blinding trachoma worldwide by 2020.

The prevalence of chlamydia trachomatis among patients with acute conjunctivitis in Kasr Alainy ophthalmology clinic

INTRODUCTION

Trachoma is a leading cause of avoidable blindness and endemic conjunctivitis in 57 countries. It infects approximately 84 million people globally, and continues to threaten over 10% of the world's population with the risk of blindness.

METHODS

This is a cross sectional descriptive study assessing patients presenting with acute conjunctivitis. A full history was taken from patients followed by examination of both eyes. A conjunctival swab was taken and a sample of tears was collected and handled at the central laboratory unit at Kasr AlAiny hospital for culture and sensitivity of the swab and ELISA for tears searching for Immunoglobulin G and Immunoglobulin M of chlamydia trachomatis.

RESULTS

The prevalence of bacterial conjunctivitis encounted for 45.7% and non-bacterial 54.3% of the studied group. The anti-chlamydial antibodies were positive in the tears of 31.1% of patients. While the other bacterial organisms responsible for 14.6%.

CONCLUSION

The study concluded that trachoma accounts for one third of the cases of acute conjunctivitis while the other bacterial organisms responsible for about 14.6%. More than half of the cases have other causes as viral, allergic, mechanical or chemical induced conjunctivitis.

Effect of water, sanitation, and hygiene on the prevention of trachoma: a systematic review and meta-analysis

BACKGROUND

Trachoma is the world's leading cause of infectious blindness. The World Health Organization (WHO) has endorsed the SAFE strategy in order to eliminate blindness due to trachoma by 2020 through "surgery," "antibiotics," "facial cleanliness," and "environmental improvement." While the S and A components have been widely implemented, evidence and specific targets are lacking for the F and E components, of which water, sanitation, and hygiene (WASH) are critical elements. Data on the impact of WASH on trachoma are needed to support policy and program recommendations. Our objective was to systematically review the literature and conduct meta-analyses where possible to report the effects of WASH conditions on trachoma and identify research gaps.

METHODS AND FINDINGS

We systematically searched PubMed, Embase, ISI Web of Knowledge, MedCarib, Lilacs, REPIDISCA, DESASTRES, and African Index Medicus databases through October 27, 2013 with no restrictions on language or year of publication. Studies were eligible for inclusion if they reported a measure of the effect of WASH on trachoma, either active disease indicated by observed signs of trachomatous inflammation or Chlamydia trachomatis infection diagnosed using PCR. We identified 86 studies that reported a measure of the effect of WASH on trachoma. To evaluate study quality, we developed a set of criteria derived from the GRADE methodology. Publication bias was assessed using funnel plots. If three or more studies reported measures of effect for a comparable WASH exposure and trachoma outcome, we conducted a random-effects meta-analysis. We conducted 15 meta-analyses for specific exposure-outcome pairs. Access to sanitation was associated with lower trachoma as measured by the presence of trachomatous inflammation-follicular or trachomatous inflammation-intense (TF/TI) (odds ratio [OR] 0.85, 95% CI 0.75-0.95) and C. trachomatis infection (OR 0.67, 95% CI 0.55-0.78). Having a clean face was significantly associated with reduced odds of TF/TI (OR 0.42, 95% CI 0.32-0.52), as were facial cleanliness indicators lack of ocular discharge (OR 0.42, 95% CI 0.23-0.61) and lack of nasal discharge (OR 0.62, 95% CI 0.52-0.72). Facial cleanliness indicators were also associated with reduced odds of C. trachomatis infection: lack of ocular discharge (OR 0.40, 95% CI 0.31-0.49) and lack of nasal discharge (OR 0.56, 95% CI 0.37-0.76). Other hygiene factors found to be significantly associated with reduced TF/TI included face washing at least once daily (OR 0.76, 95% CI 0.57-0.96), face washing at least twice daily (OR 0.85, 95% CI 0.80-0.90), soap use (OR 0.76, 95% CI 0.59-0.93), towel use (OR 0.65, 95% CI 0.53-0.78), and daily bathing practices (OR 0.76, 95% CI 0.53-0.99). Living within 1 km of a water source was not found to be significantly associated with TF/TI or C. trachomatis infection, and the use of sanitation facilities was not found to be significantly associated with TF/TI.

CONCLUSIONS

We found strong evidence to support F and E components of the SAFE strategy. Though limitations included moderate to high heterogenity, low study quality, and the lack of standard definitions, these findings support the importance of WASH in trachoma elimination strategies and the need for the development of standardized approaches to measuring WASH in trachoma control programs.

Association between water related factors and active trachoma in Hai district, Northern Tanzania

BACKGROUND

Trachoma is widely distributed in sub-Saharan Africa and is mainly associated with poor water accessibility. However, these associations have never been demonstrated in some of the communities, especially in northern Tanzania. To cover that gap, the present case control study was conducted to assess the association of water related factors, general hygiene and active trachoma among preschool and school age children in Hai district, northern Tanzania.

RESULTS

Families reported to use > 60 litres of water per day were less likely to have active disease (OR= 0.4, 95% CI: 0.1 - 0.3; P<0.001) compared to households collecting ≤ 60 litres. The risk of having trachoma increased with increase in distance to the water point (OR= 6.5, 95% CI; 1.8 - 16.7; P= 0.003). Households members who reported to use < 2 liters of water for face washing were more likely to be trachomatous (OR= 5.12, 95% CI: 1.87-14.6, P = 0.001). Increased number of preschool children in the household was also associated with increased risk of active trachoma by 2.46 folds.

CONCLUSIONS

Improving water supply near the households and providing public health education focusing on improving households socio-economic status and individual hygiene especially in pre-school children in part will help to reduce the prevalence of the disease. In addition, integrating public health education with other interventions such as medical interventions remains important.

The field-testing of a novel integrated mapping protocol for neglected tropical diseases

Background

Vertical control and elimination programs focused on specific neglected tropical diseases (NTDs) can achieve notable success by reducing the prevalence and intensity of infection. However, many NTD-endemic countries have not been able to launch or scale-up programs because they lack the necessary baseline data for planning and advocacy. Each NTD program has its own mapping guidelines to collect missing data. Where geographic overlap among NTDs exists, an integrated mapping approach could result in significant resource savings. We developed and field-tested an innovative integrated NTD mapping protocol (Integrated Threshold Mapping (ITM) Methodology) for lymphatic filariasis (LF), trachoma, schistosomiasis and soil-transmitted helminths (STH).

Methodology/Principal Findings

The protocol is designed to be resource-efficient, and its specific purpose is to determine whether a threshold to trigger public health interventions in an implementation unit has been attained. The protocol relies on World Health Organization (WHO) recommended indicators in the disease-specific age groups. For each disease, the sampling frame was the district, but for schistosomiasis, the sub-district rather than the ecological zone was used. We tested the protocol by comparing it to current WHO mapping methodologies for each of the targeted diseases in one district each in Mali and Senegal. Results were compared in terms of public health intervention, and feasibility, including cost. In this study, the ITM methodology reached the same conclusions as the WHO methodologies regarding the initiation of public health interventions for trachoma, LF and STH, but resulted in more targeted intervention recommendations for schistosomiasis. ITM was practical, feasible and demonstrated an overall cost saving compared with the standard, non-integrated, WHO methodologies.

Conclusions/Significance

This integrated mapping tool could facilitate the implementation of much-needed programs in endemic countries.

Neglected tropical diseases (NTDs) cause significant physical debilitation, lowered economic productivity, and social ostracism for afflicted individuals. Five NTDs with available preventive chemotherapy: lymphatic filariasis (LF), trachoma, schistosomiasis, onchocerciasis and the three soil-transmitted helminths (STH); have been targeted for control or elimination, but resource constraints in endemic countries have impeded progress toward these goals. We have developed an integrated mapping protocol, Integrated Threshold Mapping (ITM) for use by Ministries of Health to decide where public health interventions for NTDs are needed. We compared this protocol to the World Health Organizations disease-specific mapping protocols in Mali and Senegal. Results from both methodologies indicated the same public health interventions for trachoma, LF and STH, while the ITM methodology resulted in a more targeted intervention for schistosomiasis. Our study suggests that the integrated methodology, which is also less expensive and logistically more feasible to implement, could replace disease-specific mapping protocols in resource-poor NTD-endemic countries.

Overcoming gender inequity in prevention of blindness and visual impairment in Africa

Background:

Globally, and in Africa, after adjusting for age, women are about 1.4 times more likely to be blind than men. While women generally live longer than men, the lack of accessibility to and use of services is likely the most important reason for excess blindness in women in Africa.

Aim:

We sought to review the literature on vision loss in Africa and summarize the findings related to gender equity.

Materials and Methods:

Information from across sub-Saharan Africa was collected on the evidence of gender inequity and reasons for this inequity. Finally, the results were used to generate suggestions on how gender equity could be improved.

Results:

In all published surveys (except one), cataract surgical coverage among women was lower than cataract surgical coverage among men. Although data available are limited, similar findings appeared in the use of services for other disease conditions, notably, childhood cataract and glaucoma. Evidence suggests that a variety of approaches are needed to improve the use of eye care services. Three main strategies are needed to address gender inequity in vision loss in Africa. First, it is important to address transport needs. Second, counseling of patients and family members is required. Finally, programs need to put in place pricing systems that make the services affordable the population.

Conclusions:

VISION 2020 can be achieved in Africa, but investment is needed in a variety of strategies that will ensure that eye care services are affordable, accessible, and acceptable to women and girls.

Rates and risk factors for unfavorable outcomes 6 weeks after trichiasis surgery

PURPOSE

Several studies of trichiasis recurrence suggest an association between surgical factors and long-term recurrence, yet data on short-term risk factors are limited. This study was conducted to evaluate risk factors for early trichiasis recurrence and other unfavorable short-term outcomes.

METHODS

Trichiasis patients presenting for surgery were evaluated for presence of active trachoma and signs of cicatricial outcomes of trachoma, including number of trichiatic lashes, epilation, and entropion. Surgical factors recorded included incision length, surgery duration, and the surgeon performing the operation. Participants were followed up for 6 weeks after surgery and evaluated for eyelid closure defect and trichiasis recurrence; in addition, in two thirds of the patients, eyelid contour abnormality and granuloma formation were evaluated.

RESULTS

First-time trichiasis surgery was performed on 2615 eyelids. Of these, 2601 eyelids without surgical failure were followed up 6 weeks after surgery. Of the eyelids treated, 2.3% had recurrent trichiasis and 1.3% had an eyelid closure defect. Data on eyelid contour abnormalities and granuloma formation were recorded for 1881 eyes, with rates of 1.2% and 10.5%, respectively. Associated risk factors differed by outcome. Surgeon was predictive of eyelid closure defect and granuloma formation. Eyelids with short incisions were nearly four times more likely to have recurrent trichiasis (95% confidence interval, 1.7-9.3). Baseline trichiasis severity was predictive of eyelid contour abnormalities and recurrent trichiasis. Epilation was associated with granuloma formation, but was protective against eyelid closure defect.

CONCLUSIONS

Surgical factors are important predictors of unfavorable outcomes in the weeks immediately after surgery. Although the overall rate of serious uncorrectable unfavorable outcomes was very low, the high rate of granuloma formation, which can be treated by removal, highlights the need for follow-up of patients after trichiasis surgery. (ClinicalTrials.gov number, NCT00347776.).

Blinding Trachoma in the Northern Provinces of Vietnam—A Cross Sectional Survey

INTRODUCTION

A prevalence study was conducted in 2001 as part of the SAFE Trachoma Control initiatives in twelve districts of eight northern provinces of Vietnam. The authors present the magnitude and some risk factors of trachomatous trichiasis (TT), trachomatous scarring (TS) and trachomatous corneal opacity (TCO).

METHODS

Ophthalmologists examined 43,677 people of more than 34 years of age, randomly selected. Ophthalmic loupe, torchlight and the trachoma grading card recommended by WHO were used for this examination.

RESULTS

The prevalence of TT was 7.31% (95% CI 7.07-7.55) and 382,950 persons with TT were included in the study population. The rate was higher in females (8.92%) than in males (5.35%). The rate was 13.7% in the district of Me Linh in Vinh Phuc province and in the districts of Ha Tay and Khoai Chau in Hung Yen province, while in the districts of Na Ri (Bac Kan province), Cam Xuyen (Ha Tinh province) and Van Yen (Yen Bai province), the prevalence of TT was less than 2%. The TT rate in the plains was 13%, while in mountainous, coastal and delta terrains, the rate fell to 2.4%, 3.5% and 9.4% respectively. The prevalence of TS and TCO was 8.42% (95% CI 8.21-8.61) and 1.1% (95% CI 1.00-1.20) respectively.

CONCLUSION

Although the magnitude of TT is high, the problem of TCO seems to be less serious. The goal of eliminating blinding trachoma from the study area by 2010 represents a big challenge. Based on these survey estimates, the national program could plan resources for the 'S' strategy of trachoma control (surgery for those at immediate risk of blindness).

Trachoma survey methods: a literature review

Reliable population-based prevalence data are essential for planning, monitoring and evaluating trachoma control programmes and understanding the scale of the problem, yet they are not currently available for 22 out of 56 trachoma-endemic countries. Three survey methods have been advocated for trachoma: cluster random sampling (CRS); trachoma rapid assessment (TRA); and acceptance sampling trachoma rapid assessment (ASTRA). Our review highlights the benefits of CRS being simple, efficient, repeatable and giving population-based prevalence estimates of all signs of trachoma. There are limitations to TRA, which include: non-representative sampling; does not estimate prevalence; and lacks consistency and accuracy. ASTRA advocates small sample sizes but it is relatively complex, may result in imprecise prevalence estimates and does not estimate cicatricial signs of trachoma. We conclude that CRS should therefore remain the 'gold' standard for trachoma surveys. However, among the CRS surveys reviewed, we also found several methodological deficiencies of sample-size calculations, standardization of trachoma graders, reporting of confidence intervals of prevalence estimates, variability of age groups for presentation of age-specific prevalence, and lack of estimation of district prevalence estimates. Properly conducted surveys will be crucial if the objective of global elimination of blinding trachoma is to be charted and realized. Harmonization of survey methods will enhance the conduct and comparability of trachoma surveys needed for reliable mapping of prevalence within endemic countries. Consistent with WHO recommendations, we advocate for continued use of CRS as the survey design of choice for trachoma control programmes and propose ways of improving future surveys based on this method.

Trachoma

Trachoma is a keratoconjunctivitis caused by ocular infection with Chlamydia trachomatis. Repeated or persistent episodes lead to increasingly severe inflammation that can progress to scarring of the upper tarsal conjunctiva. Trichiasis develops when scarring distorts the upper eyelid sufficiently to cause one or more lashes to abrade the cornea, scarring it in turn and causing blindness. Active trachoma affects an estimated 84 million people; another 7.6 million have end-stage disease, of which about 1.3 million are blind. Trachoma should stand on the brink of extinction thanks to a 1998 initiative launched by WHO--the Global Elimination of Trachoma by 2020. This programme advocates control of trachoma at the community level with four inter-related population-health initiatives that form the SAFE strategy: surgery for trichiasis, antibiotics for active trachoma, facial cleanliness, and environmental improvement. Evidence supports the effectiveness of this approach, and if current world efforts continue, blinding trachoma will indeed be eliminated by 2020.

Trachoma surveys 2000-2005: results, recent advances in methodology, and factors affecting the determination of prevalence

With the advent of VISION 2020 and GET 2020 inaugurated by the World Health Organization, it is timely to provide an update of the methodology employed in trachoma surveys, given that a significant number of individuals in many undeveloped and developing countries still suffer from this ophthalmic disease. The advent of Trachoma Rapid Assessment and Asymmetrical Sampling Rapid Trachoma Assessment has enabled faster identification of trachoma-endemic areas, though population-based surveys are still required prior to intervention. Research into factors affecting prevalence determination has shown that mobility, clustering, and seasonality should all be taken into account regarding survey design. In addition, recent advances in laboratory testing have given us new insight into trachoma infection patterns and a better understanding of the disease course. In this review, we examine advances in survey methodology and the results of trachoma surveys since 1999, and other issues relevant to the determination of trachoma prevalence. Based on recent findings, we recommend that pooled nucleic acid amplification testing be used to augment clinical assessment in areas where trachoma prevalence is greater than 20%. Further, we suggest that trachoma follicular and trachoma follicular or trachoma intense, as markers of the disease, be reported separately.

Uptake of trichiasis surgical services in Tanzania through two village-based approaches

AIM

To determine the effectiveness of village-based strategies (using school teachers and village leaders) to increase the use of surgical services.

METHODS

A cohort study was conducted in Tanzania using two village strategies (village leader and school teachers); trichiasis surgical uptake and the factors associated with uptake were measured after 1 year.

RESULTS

The trichiasis surgical coverage at baseline was 16.9%; 200 patients who needed surgery were identified. One year later, we were able to re-examine and interview 163 of these patients. The surgical uptake among these patients was 44.8% (95% CI 37.2% to 52.4%). Patients in the school-teacher programme had a 36.5% uptake compared with 52.1% for those in the village-leader programme. No difference was observed in uptake by age or sex. Uptake was highest among those coming from multiple-generation households and those with more household wealth. Of the 90 people who still had not had surgery, 20 (22.2%) reported seeking surgery, but failing to receive it because of barriers at the provider side.

CONCLUSIONS

Improved surgical uptake for trachomatous trichiasis was achieved by using village-based promotion efforts and surgical services at existing health clinics. Even with free surgery at health clinics, indirect costs and social support barriers limit utilisation by the most vulnerable, the poorest and those living in single-generation households. Problems at the provider level also create barriers for patients who need surgery.

Routine bilamellar tarsal rotation surgery for trachomatous trichiasis: short-term outcome and factors associated with surgical failure

PURPOSE

To determine risk factors for early failure of the bilamellar tarsal rotation procedure in trachomatous trichiasis.

METHODS

This was a prospective study in which the bilamellar tarsal rotation procedure was performed on 638 eyelids in Menofiya governorate in Egypt over a 4-year period. An analysis was performed to determine the incidence of early surgical failure (defined as one or more lashes touching the eyeball) after 8 weeks and to determine the risk factors for these failures.

RESULTS

Follow-up data were available on 599 eyes at 8 to 10 weeks after surgery. Considering all eyes, failure (one or more lashes touching the eyeball) was noted in 98 eyes (16.4%). Failure was associated with preoperative corneal staining (RR, 3.27; 95% CI, 2.34 to 4.57), preoperative corneal opacity (RR, 1.64; 95% CI, 1.15 to 2.34), the use of silk sutures (RR, 54.82; 95% CI, 7.72 to 389.4), and the use of 4 or more sutures (RR, 1.24; 95% CI, 1.04 to 1.48).

CONCLUSIONS

The finding that specific sutures or needles was associated with early failure of the bilamellar tarsal plate rotation procedure for trachomatous trichiasis was unexpected and deserves further study.

Contribution of sex-linked biology and gender roles to disparities with trachoma

Globally, trachoma is the leading infectious cause of blindness. Survey data consistently show that trachoma-related blindness is two to four times higher in women than men. Tracing the increased risk for trachoma and its consequences for women suggests that other factors besides biology may contribute. Understanding the reasons for the excess risk for and consequences of trachoma in girls and women requires examining a number of issues: Are girls and women more biologically susceptible to the consequences of infection with Chlamydia trachomatis? Could other factors help explain the excess of conjunctival scarring and trichiasis in women? Do gender roles affect the risk for trachoma and its consequences? Are women more likely to have recurrence after trichiasis surgery compared to men? This article explores the answers to these questions.

Active trachoma in children aged three to nine years in rural communities in Ethiopia: prevalence, indicators and risk factors

Trachoma is the most important infectious cause of blindness worldwide. In two rural populations in Ethiopia, a programme of preventative and treatment measures was initiated in May 2002. A baseline survey was conducted to evaluate the effect of this programme on the prevalence of active trachoma. A total of 1960 children aged 3-9 years, from 915 households in 40 communities, were examined for the presence of active trachoma. Demographic and household information was collected using questionnaires and household amenities and environmental conditions were observed. Overall, 72% of children had active trachoma. Twenty percent of children aged nine years had trachomatous scarring. In children, discharge in the eyes and flies on the eyes were significant indicators of trachoma (odds ratio [OR] = 3.0, 95% CI 1.94-4.55 and OR = 3.4, 95% CI 2.37-4.88, respectively). Frequency of washing children, a clean environment and hygienic disposal of excrement were significant preventative factors for active trachoma. Prevalence of active trachoma varies widely between and within districts. Risk factors comprise a mix of individual characteristics and household factors. This study demonstrates the need for broad target interventions and a flexible approach to the prevention of trachoma in high prevalence endemic rural populations.

Trachoma: new assault on an ancient disease

Trachoma is the leading infectious cause of blindness worldwide. The World Health Organization (WHO) estimated that approximately 5.9 million persons are blind or have severe vision-loss as a result of trachoma, and another 10 million are at high risk. Trachoma preferentially affects the most deprived communities, and within these communities, women and children bear the brunt of the burden. In recent years, there has been a renewed focus on research and heightened enthusiasm for strengthening trachoma control programs in afflicted countries. WHO has convened an alliance of member countries, non-governmental organizations, and other partners for the Global Elimination of Blinding Trachoma by the year 2020, and endorsed the multi-faceted SAFE strategy for trachoma control. SAFE-Surgery, Antibiotics, Face-washing, and Environmental improvement-has incorporated sound research on elements likely to reduce trachoma, and trachomatis blindness, in endemic communities. This review summarizes current knowledge about trachoma and its causative agent, Chlamydia trachomatis, the epidemiology and risk factors for trachoma as a prelude to reviewing the SAFE strategy. While ongoing research to support the knowledge base for SAFE must continue to be a priority, the full implementation of SAFE is the best hope for countries to reduce the global burden of blindness from this preventable cause.

Sociodemographic characteristics associated with blindness in a Nile Delta governorate of Egypt

BACKGROUND

Globally, blindness is associated with old age and being female. Other sociodemographic and socioeconomic status characteristics associated with blindness have included educational attainment, and occupation. These factors reflect exposure to specific risk factors for blinding eye diseases and utilisation of preventive and curative services by specific sectors of the population.

METHODS

A population based survey of blindness and trachoma was conducted in Menofiya governorate in Egypt. 3322 adults 50 years of age and over were sampled from throughout the governorate (population 2.7 million). Visual acuity and clinical conditions were recorded and interviews with respondents were conducted.

RESULTS

Overall, blindness (<6/60 presenting vision in the better eye) was recorded in 13% of the study population. Besides age and sex, other factors associated with blindness (logistic regression) were marital status and poor sanitation in the household.

CONCLUSION

Socioeconomic status does not appear to be a significant factor associated with blindness in adults in this setting. Instead, sociocultural factors, in particular, characteristics associated with gender sensitive decision making within households, are likely to be more important considerations in understanding blindness in these communities. Successfully combating blindness in the Nile Delta of Egypt will require gender sensitive efforts aimed at timely and effective utilisation of eye care services.

Blinding trachoma: prevention with the safe strategy

Trachoma, the second leading cause of blindness worldwide, differentially affects the poorest communities, which may have the least access to resources. With the establishment of the Global Elimination of Blinding Trachoma by 2020 (GET 2020) goal, the World Health Organization has set an ambitious target for country programs. The currently recommended surgery for trichiasis/entropion, antibiotics for active disease, facial cleanliness, and environmental change to reduce transmission (SAFE) strategy targets all key elements believed to be necessary for a short- and long-term intervention program. This report reviews the need for a multi-faceted strategy, and the evidence supporting the elements of SAFE. Concerns about the implementation are discussed. Additional research is suggested that will enhance the implementation of the SAFE strategy. In the current climate of significant political and social momentum for trachoma control, the SAFE strategy is a safe bet to accomplish the elimination of blinding trachoma.

The global elimination of blinding trachoma: progress and promise

Trachoma is the world's leading cause of preventable blindness. It affects approximately 150 million people living in the world's poorest, rural communities and causes an estimated loss of $2.9 billion in productivity annually. In 1985, the Edna McConnell Clark Foundation joined with the World Health Organization to support studies on trachoma epidemiology and control, resulting in the elaboration of the surgery, antibiotics, facial cleanliness and environmental improvement (SAFE) strategy as the basis for the elimination of this blinding disease. Founded in 1998 by the Clark Foundation and Pfizer, Inc., the International Trachoma Initiative (ITI) is the only organization dedicated to eliminating blinding trachoma through support to national control programs. The availability of donated Zithromax (azithromycin) by Pfizer, Inc. has been paramount to the support of the ITI for implementation of SAFE in 10 country programs. The program has made considerable progress in four years. More than seven million individuals have received treatment, resulting in a cumulative reduction of 50% in active disease rates in children. More than 60,000 have also benefited from lid surgery that has halted progression to blindness. Morocco is expecting to attain the elimination of blinding trachoma by 2005. However, the challenges facing the goal of global elimination by 2020 involve a vital program expansion, increased financial and technical support, environmental improvement, and continued advocacy efforts.