Interventions for trachoma trichiasis

Impact of refresher training on the outcomes of trachomatous trichiasis surgery

BACKGROUND/AIMS

Trachomatous trichiasis (TT) is a severe consequence of chronic inflammation/conjunctival scarring resulting from trachoma, the leading infectious cause of blindness worldwide. Our prospective cohort study evaluated the effectiveness of refresher training (RT) for experienced surgeons (1-22 years) on the outcomes of upper lid (UL) TT surgery in rural Ethiopia.

METHODS

Patients undergoing UL TT surgery in at least one eye by a participating surgeon were included. Patients were split into two cohorts: patients enrolled prior to (C1) and after (C2) RT. RT consisted of a 1-week programme with practice on a HEAD START mannequin and supportive supervision in live surgery by expert trainers. Data were collected at preoperative enrolment, and at 6-month and 12-month follow-up visits. The primary outcome was development of postoperative TT (PTT). A series of multivariate generalised estimating equations were fit to model PTT involving potential covariates of interest.

RESULTS

A total of 261 eyes contributed by 173 patients were studied between 2017 and 2019. By 1-year postoperatively, 37/128 eyes (28.9%) in C1 and 22/133 eyes (16.5%) in C2 had developed PTT (p=0.03). Other than surgeon RT participation, no factors studied were associated with differences in PTT.

CONCLUSION

Our results indicate a significant reduction in the risk of PTT after experienced surgeons' participation in RT as compared with eyes receiving surgery before RT. This observation suggests a significant potential benefit of the RT with HEAD START mannequin practice and supportive supervision during surgery, and suggests RT may be a valuable strategy to improve surgical outcomes.

Trichiasis in cicatricial ocular surface disease: a multi-center comparison of electroepilation versus eyelash resection outcomes

PURPOSE

To evaluate the outcomes of trichiasis (excluding entropion) management in non-trachomatous cicatricial ocular surface diseases.

METHODS

This is a multicenter, retrospective study of 59 patients with trichiasis who were managed using two different techniques: electroepilation using radiofrequency (RF) cautery and eyelash resection. The assessed outcomes were residual trichiasis at 6 weeks, 6, and 12 months of follow-up and the number of procedures needed.

RESULTS

41 patients (90 eyelids) underwent electroepilation, and 18 (41 eyelids) were managed with eyelash resection. All patients belonged to either Indian or Japanese ethnicity. Most patients in both groups had Stevens-Johnson Syndrome (63.4% vs. 88.9%). The mean age (43.2 vs. 46 years), disease duration (122 vs. 192.4 months), median trichiasis grade (2 vs. 2), and involvement of upper eyelids (53/90 vs. 23/41) were similar in the two groups. At six weeks, 48.9% of eyelids that underwent electroepilation had no trichiasis, and recurrences were managed with repeat electroepilation (6 eyelids) and mucous membrane grafting (10 eyelids), and 35 eyelids opted for manual epilation, giving 67.8% success at a mean follow-up of 20 months. The eyelash resection group had 75.6% success at 6 months, and recurrences were managed using lid splitting and eyelash resection, resulting in 100% success at a mean follow-up of 79 months. More interventions were needed in the electroepilation group compared to eyelash resection.

CONCLUSION

Eyelash resection of the trichiatic eyelashes achieves a better success rate than electroepilation in cicatricial ocular surface disorders. Following electroepilation, one needs multiple interventions to resolve trichiasis.

Prevalence of Post-Operative Trichiasis in Southern Ethiopia, 2021: A Community Based Cross Sectional Study

Background

Post-operative trichiasis (PTT) is a major challenge following corrective eyelid surgery for trachomatous trichiasis. There is a scarcity of research on post-operative trichiasis in Southern Ethiopia, particularly in the study area. This study aimed to assess the prevalence of post-operative trichiasis in patients who underwent corrective surgery.

Objective

To assess the prevalence of post-operative trichiasis in the Gamo Zone in Southern Ethiopia in 2021.

Methods

A descriptive community-based cross-sectional study was conducted in the Dita district, Southern Ethiopia. The data were collected between 2014 and 2020. Three Qualified trachoma trichiasis (TT) graders working on a trachoma impact survey were recruited for this study. Eye examinations were performed by graders on all study subjects using a loupe to identify post-operative trichiasis. All patients underwent upper eyelid surgery only. A systematic sampling technique was used to select 459 participants from the TT Surgery Logbook.

Results

Of the 459 study participants, more than three quarter 353 (76.9%) were female. The mean age of the study subjects was 48.38 years with a standard deviation of +-10.4. A total of 10 upper eyelids (7 bilateral and 3 left upper eyelids) underwent PTT. The prevalence of post-operative trichiasis in the study area was 2.2% (95% CI: 0.9-3.5%. Fourteen (4.7%) unoperated upper eyelids developed trichiasis infection. A few patients had left and right lower eyelid trichiasis (6/459 [1.3%] and 3/459 [0.7%], respectively).

Conclusion and Recommendation

The prevalence of post-operative trichiasis in the study area was similar to that recommended by the World Health Organization (WHO) recommendation range. Trachoma trichiasis was observed on the lower and upper unoperated eyelids of the study participants. Therefore, sustainable interventions should be considered in the study area for all the components of the SAFE strategy, particularly on S component.

The Association Between the Severity of Trachomatous Scarring and Trachomatous Trichiasis Severity in Surgical Patients in Tanzania

PURPOSE

To determine the association between the severity of trachomatous conjunctival scarring (TS) of the upper eyelid conjunctiva and trachomatous trichiasis (TT) severity in TT surgical patients.

METHODS

A cross-sectional study was conducted amongst adults with TT who were referred to surgical camps in Bahi District, Tanzania, for TT surgery. Participants underwent ocular examination. The presence and severity of TS was evaluated in photographs of the everted upper eyelid. TT severity was assessed at the time of the ocular exam based on the number of lashes touching the globe and/or evidence and extent of epilation. Ordinal logistic models were used to examine the association between the severity of TS and TT severity.

RESULTS

A total of 627 eyes of 388 participants were included. Mean age was 65 years (ranging from 21-98), 81% were females, and 62% had bilateral TT. 93% of eyes with any TT had at least moderate TS; 62% of eyes had severe TS. An increase in TS severity was associated with an increase in the severity of TT. Using as a reference eyes with none to mild TS, in eyes with moderate TS the odds of increased severity of TT was 1.30 (95% CI 0.67-2.51), in eyes with severe TS the odds was 4.20 (95% CI 2.23-7.92).

CONCLUSION

In cases of trachomatous trichiasis presenting for surgery, the severity of TT was significantly associated with the severity of TS with almost all cases of TT having moderate or severe scarring.

Baseline, Impact and Surveillance Trachoma Prevalence Surveys in Burundi, 2018-2021

PURPOSE

Trachoma is an eye disease caused by the bacterium Chlamydia trachomatis (Ct). It can lead to permanent vision loss. Since 2007, Burundi has included trachoma elimination as part of its fight against neglected tropical diseases and blindness. This study presents the results of trachoma baseline, impact and surveillance surveys conducted in Burundi between 2018 and 2021.

METHODS

Areas were grouped into evaluation units (EU) with resident populations of between 100,000 and 250,000 people. Baseline surveys were conducted in 15 EUs, impact surveys in 2 EUs and surveillance surveys in 5 EUs; in each survey, 23 clusters of about 30 households were included. Consenting residents of those households were screened for clinical signs of trachoma. Access to water, sanitation and hygiene (WASH) was recorded.

RESULTS

A total of 63,800 individuals were examined. The prevalence of TF in 1-9-year-olds was above the elimination threshold of 5% in a single EU at baseline, but fell below the threshold in subsequent impact and surveillance surveys. The prevalence of TT was below the 0.2% elimination threshold in ≥15-year-olds in all EUs surveyed. A high proportion (83%) of households had access to safe drinking water, while only a minority (~8%) had access to improved latrines.

CONCLUSION

Burundi has demonstrated the prevalence levels necessary for trachoma elimination status. With continued effort and the maintenance of existing management plans, trachoma elimination in Burundi is within reach.

The conjunctival transcriptome in Ethiopians after trichiasis surgery: associations with the development of eyelid contour abnormalities and the effect of oral doxycycline treatment

Background: Surgery to correct trichiasis is a key component of the World Health Organisation trachoma control strategy, however unfavourable outcomes such as eyelid contour abnormalities (ECA) following surgery are relatively common. This study aimed to understand the transcriptional changes associated with the early development of ECA and the impact of doxycycline, which has anti-inflammatory and anti-fibrotic properties, upon these transcription patterns. Methods: One thousand Ethiopians undergoing trichiasis surgery were enrolled in a randomised controlled trial following informed consent. Equal groups of randomly assigned individuals were orally administered with 100mg/day of doxycycline (n=499) or placebo (n=501) for 28 days. Conjunctival swabs were collected immediately prior to surgery and at one- and six-months post-surgery. 3' mRNA sequencing was performed on paired baseline and one-month samples from 48 individuals; 12 in each treatment/outcome group (Placebo-Good outcome, Placebo-Poor outcome, Doxycycline-Good outcome, Doxycycline-Poor outcome). qPCR validation was then performed for 46 genes of interest in 145 individuals who developed ECA at one month and 145 matched controls, using samples from baseline, one and six months. Results: All treatment/outcome groups upregulated genes associated with wound healing pathways at one month relative to baseline, however no individual differences were detected between groups. The summed expression of a highly coexpressed cluster of pro-fibrotic genes was higher in patients that developed ECA in the placebo group relative to controls. qPCR validation revealed that all genes in this cluster and a number of other pro-inflammatory genes were strongly associated with ECA, however these associations were not modulated by trial arm. Conclusions: The development of post-operative ECA is associated with overexpression of pro-inflammatory and pro-fibrotic genes including growth factors, matrix metalloproteinases, collagens and extracellular matrix proteins. There was no evidence that doxycycline modulated the association between gene expression and ECA.

Forecasting Trachoma Control and Identifying Transmission-Hotspots

Background

Tremendous progress towards elimination of trachoma as a public health problem has been made. However, there are areas where the clinical indicator of disease, trachomatous inflammation—follicular (TF), remains prevalent. We quantify the progress that has been made, and forecast how TF prevalence will evolve with current interventions. We also determine the probability that a district is a transmission-hotspot based on its TF prevalence (ie, reproduction number greater than one).

Methods

Data on trachoma prevalence come from the GET2020 global repository organized by the World Health Organization and the International Trachoma Initiative. Forecasts of TF prevalence and the percent of districts with local control is achieved by regressing the coefficients of a fitted exponential distribution for the year-by-year distribution of TF prevalence. The probability of a district being a transmission-hotspot is extrapolated from the residuals of the regression.

Results

Forecasts suggest that with current interventions, 96.5% of surveyed districts will have TF prevalence among children aged 1–9 years <5% by 2030 (95% CI: 86.6%–100.0%). Districts with TF prevalence < 20% appear unlikely to be transmission-hotspots. However, a district having TF prevalence of over 28% in 2016–2019 corresponds to at least 50% probability of being a transmission-hotspot.

Conclusions

Sustainable control of trachoma appears achievable. However there are transmission-hotspots that are not responding to annual mass drug administration of azithromycin and require enhanced treatment in order to reach local control.

Ophthalmology training in sub-Saharan Africa: a scoping review

Sub-Saharan Africa is home to 12% of the global population, and 4.3 million are blind and over 15 million are visually impaired. There are only 2.5 ophthalmologists per million people in SSA. Training of ophthalmologists is critical. We designed a systematic literature review protocol, searched MEDLINE Ovid and Embase OVID on 1 August 2019 and limited these searches to the year 2000 onwards. We also searched Google Scholar and websites of ophthalmic institutions for additional information. We include a total of 49 references in this review and used a narrative approach to synthesise the results. There are 56 training institutions for ophthalmologists in eleven Anglophone, eleven Francophone, and two Lusophone SSA countries. The median duration of ophthalmology training programmes was 4 years. Most curricula have been regionally standardised. National, regional and international collaborations are a key feature to ophthalmology training in more than half of ophthalmology training programmes. There is a drive, although perhaps not always evidence-based, for sub-specialisation in the region. Available published scientific data on ophthalmic medical and surgical training in SSA is sparse, especially for Francophone and Lusophone countries. However, through a broad scoping review strategy it has been possible to obtain a valuable and detailed view of ophthalmology training in SSA. Training of ophthalmologists is a complex and multi-faceted task. There are challenges in appropriate selection, capacity, and funding of available training institutions. Numerous learning outcomes demand curriculum, time, faculty, support, and appropriate assessment. There are opportunities provided by modern training approaches. Partnership is key.

Systematic review of the incidence of post-operative trichiasis in Africa

BACKGROUND

Surgery for trichiasis is one of the pillars of the World Health Organization's strategy for global elimination of trachoma as a public health problem. A high incidence of post-operative trichiasis or other poor surgical outcomes could jeopardize these efforts. In this review, we aimed to summarize the reported incidence of post-operative trichiasis and other poor outcomes of trichiasis surgery in Africa.

METHODS

We conducted a systematic literature search using PubMed, Academic Search Premier, Africa-Wide Information, CINAHL and Health Source Nursing through EBSCOhost, Web of Science, and the Cochrane Central Register of Controlled Trials. Reference lists of included studies were also reviewed to identify further potentially relevant publications. All observational and interventional studies that measured post-operative trichiasis in Africa as an outcome of trichiasis surgery were included.

RESULTS

Thirty-five papers reporting on 22 studies (9 interventional,13 observational; total 13,737 participants) met the inclusion criteria. The reported incidence of post-operative trichiasis in the included studies ranged from 2% (at 6 weeks after bilamellar tarsal rotation) to 69% (at 3 weeks after anterior lamellar repositioning). The incidence varied by surgical procedure, study design, and length of follow-up.

CONCLUSION

Trichiasis surgical outcomes should be improved. National trachoma programmes could benefit from identifying and adopting strategies to improve the performance and quality of their surgical service.

Integrating Face Washing into a School-Based, Handwashing Behavior Change Program to Prevent Trachoma in Turkana, Kenya

Trachoma is the leading infectious cause of blindness, and facial cleanliness is associated with reduced odds of trachomatous inflammation and Chlamydia trachomatis infection, but there is little evidence of how to drive this behavior change at scale. We report the results of a program integrating face washing into a school-based handwashing promotion program in Turkana County, Kenya. Children aged 5–15 years participated in an intervention delivered to schools in two phases, along with a third phase receiving the intervention after the evaluation, which served as a control. The primary outcome was the number of face washing events that took place when handwashing occurred, which was measured by a 3-hour structured observation at all 67 schools, and a total of 3,871 handwashing events were observed. Differences in observed in face washing behavior between each phase and the control schools were calculated using log-binomial regression with clustering at the school level, whereas survey responses on knowledge of trachoma transmission and prevention were compared using χ² tests adjusted for clustering at the school level. Face washing during handwashing events was higher in schools after 12 months (59.3%) and 20 months (44.2%) than in control schools (18.7%, P < 0.001). Trachoma knowledge was higher in schools evaluated after 12 months (80%) and 20 months (70%) than in control schools (42%, P < 0.001), and knowledge of some of key preventive behaviors was higher in intervention schools. Integrating face washing messages into school-based handwashing promotion programs increased face washing, which may help to prevent trachoma when combined with other interventions.

Association of environmental risk factors and trachoma in Gashoho Health District, Burundi

Background

Burundi is currently not meeting targets for elimination of trachoma and trichiasis by 2020 (GET2020). The recommended SAFE strategy (Surgery, antibiotics, face washing and environmental improvement) is currently not fully implemented in many areas of Burundi. The existence of associations between face-washing, sanitation and trachoma prevalence remain undocumented.

Methods

A convenience sample of 468 individuals from 117 households was drawn from attendees at trachoma clinics set up in four villages. Trachoma status, sex and age were recorded for all household members. Adult household members were surveyed about access to clean water and toilets, and knowledge of trachoma risk factors. Associations between cases of active trachoma per household and environmental risk factors were evaluated using generalised estimating equations.

Results

The overall prevalence of active trachoma was 7.1% (95% CI 5.0–9.6%), but 19.5% (95% CI13.7–26.4%) in children under nine years old. 0.9% (95% CI 0.3–2.0) of participants had trichiasis. Access to a sanitary toilet more than halved the odds of active trachoma (OR 0.43, 95% CI 0.25–0.74%), however, participants did not appreciate this association.

Conclusion

Access to sanitation was associated with the occurrence of active trachoma. Future research should focus on whether improving knowledge of and access to sanitation might reduce trachoma prevalence.

Antibiotics for trachoma

BACKGROUND

Trachoma is the world's leading infectious cause of blindness. In 1996, WHO launched the Alliance for the Global Elimination of Trachoma by the year 2020, based on the 'SAFE' strategy (surgery, antibiotics, facial cleanliness, and environmental improvement).

OBJECTIVES

To assess the evidence supporting the antibiotic arm of the SAFE strategy by assessing the effects of antibiotics on both active trachoma (primary objective), Chlamydia trachomatis infection of the conjunctiva, antibiotic resistance, and adverse effects (secondary objectives).

SEARCH METHODS

We searched relevant electronic databases and trials registers. The date of the last search was 4 January 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that satisfied either of two criteria: (a) trials in which topical or oral administration of an antibiotic was compared to placebo or no treatment in people or communities with trachoma, (b) trials in which a topical antibiotic was compared with an oral antibiotic in people or communities with trachoma. We also included studies addressing different dosing strategies in the population.  DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We identified 14 studies where individuals with trachoma were randomised and 12 cluster-randomised studies. Any antibiotic versus control (individuals)Nine studies (1961 participants) randomised individuals with trachoma to antibiotic or control (no treatment or placebo). All of these studies enrolled children and young people with active trachoma. The antibiotics used in these studies included topical (oxy)tetracycline (5 studies), doxycycline (2 studies), and sulfonamides (4 studies). Four studies had more than two study arms. In general these studies were poorly reported, and it was difficult to judge risk of bias.These studies provided low-certainty evidence that people with active trachoma treated with antibiotics experienced a reduction in active trachoma at three months (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.69 to 0.89; 1961 people; 9 RCTs; I² = 73%) and 12 months (RR 0.74, 95% CI 0.55 to 1.00; 1035 people; 4 RCTs; I² = 90%). Low-certainty evidence was available for ocular infection at three months (RR 0.81, 95% CI 0.63 to 1.04; 297 people; 4 RCTs; I² = 0%) and 12 months (RR 0.25, 95% CI 0.08 to 0.78; 129 people; 1 RCT). None of these studies assessed antimicrobial resistance. In those studies that reported harms, no serious adverse effects were reported (low-certainty evidence).Oral versus topical antibiotics (individuals)Eight studies (1583 participants) compared oral and topical antibiotics. Only one study included people older than 21 years of age. Oral antibiotics included azithromycin (5 studies), sulfonamides (2 studies), and doxycycline (1 study). Topical antibiotics included (oxy)tetracycline (6 studies), azithromycin (1 study), and sulfonamide (1 study). These studies were poorly reported, and it was difficult to judge risk of bias.There was low-certainty evidence of little or no difference in effect between oral and topical antibiotics on active trachoma at three months (RR 0.97, 95% CI 0.81 to 1.16; 953 people; 6 RCTs; I² = 63%) and 12 months (RR 0.93, 95% CI 0.75 to 1.15; 886 people; 5 RCTs; I² = 56%). There was very low-certainty evidence for ocular infection at three or 12 months. Antimicrobial resistance was not assessed. In those studies that reported adverse effects, no serious adverse effects were reported; one study reported abdominal pain with azithromycin; one study reported a couple of cases of nausea with azithromycin; and one study reported three cases of reaction to sulfonamides (low-certainty evidence).Oral azithromycin versus control (communities)Four cluster-randomised studies compared antibiotic with no or delayed treatment. Data were available on active trachoma at 12 months from two studies but could not be pooled because of reporting differences. One study at low risk of bias found a reduced prevalence of active trachoma 12 months after a single dose of azithromycin in communities with a high prevalence of infection (RR 0.58, 95% CI 0.52 to 0.65; 1247 people). The other, lower quality, study in low-prevalence communities reported similar median prevalences of infection at 12 months: 9.3% in communities treated with azithromycin and 8.2% in untreated communities. We judged this moderate-certainty evidence for a reduction in active trachoma with treatment, downgrading one level for inconsistency between the two studies. Two studies reported ocular infection at 12 months and data could be pooled. There was a reduction in ocular infection (RR 0.36, 0.31 to 0.43; 2139 people) 12 months after mass treatment with a single dose compared with no treatment (moderate-certainty evidence). There was high-certainty evidence of an increased risk of resistance of Streptococcus pneumoniae, Staphylococcus aureus, and Escherichia coli to azithromycin, tetracycline, and clindamycin in communities treated with azithromycin, with approximately 5-fold risk ratios at 12 months. The evidence did not support increased resistance to penicillin or trimethoprim-sulfamethoxazole. None of the studies measured resistance to C trachomatis. No serious adverse events were reported. The main adverse effect noted for azithromycin (˜10%) was abdominal pain, vomiting, and nausea.Oral azithromycin versus topical tetracycline (communities)Three cluster-randomised studies compared oral azithromycin with topical tetracycline. The evidence was inconsistent for active trachoma and ocular infection at three and 12 months (low-certainty evidence) and was not pooled due to considerable heterogeneity. Antimicrobial resistance and adverse effects were not reported.Different dosing strategiesSix studies compared different strategies for dosing. There were: mass treatment at different dosing intervals; applying cessation or stopping rules to mass treatment; strategies to increase mass treatment coverage. There was no strong evidence to support any variation in the recommended annual mass treatment.

AUTHORS' CONCLUSIONS

Antibiotic treatment may reduce the risk of active trachoma and ocular infection in people infected with C trachomatis, compared to no treatment/placebo, but the size of the treatment effect in individuals is uncertain. Mass antibiotic treatment with single dose oral azithromycin reduces the prevalence of active trachoma and ocular infection in communities. There is no strong evidence to support any variation in the recommended periodicity of annual mass treatment. There is evidence of an increased risk of antibiotic resistance at 12 months in communities treated with antibiotics.

A Population-Based Trachoma Prevalence Survey Covering Seven Districts of Sangha and Likouala Departments, Republic of the Congo

PURPOSE

We set out to estimate the prevalence of trachoma and access to water and sanitation in seven suspected-trachoma-endemic districts of northern Congo, surveyed as a single evaluation unit.

METHODS

From a complete list of rural villages in the seven districts, we systematically selected 22 with probability proportional to village size. In selected villages, we included all households where there were fewer than 25 in total, or used compact segment sampling to select a group of approximately 20 households by random draw. In each selected household, all consenting residents aged ≥1 year were examined by Global Trachoma Mapping Project-certified trachoma graders, and data collected on household-level access to water and sanitation.

RESULTS

In November and December 2015, 466 households were visited in 22 villages, and 2081 (88%) of 2377 residents of those households were examined. No examined individual had trichiasis. The age-adjusted prevalence of the active trachoma sign trachomatous inflammation-follicular (TF) in 1-9-year-olds was 2.5% (95%CI 0.9-4.5%). Only 39% (95%CI 35-44%) of households had access to an improved source of drinking water. Only 10% (95%CI 7-13%) of households had access to an improved sanitation facility.

CONCLUSION

Trachoma is not a public health problem in this part of Congo. Access to water and sanitation is inadequate.

Impact Survey Results after SAFE Strategy Implementation in 15 Local Government Areas of Kebbi, Sokoto and Zamfara States, Nigeria

Purpose: To determine prevalence of trachoma after interventions in 15 local government areas (LGAs) of Kebbi, Sokoto and Zamfara States, Nigeria.

Methods: A population-based impact survey was conducted in each LGA using Global Trachoma Mapping Project (GTMP) protocols. In each LGA, 25 villages were selected, except in Arewa LGA, where we selected 25 villages from each of four subunits to obtain finer-resolution prevalence information. Villages were selected with probability proportional to size. In each village, 25 households were enrolled and all consenting residents aged ≥1 year were examined by GTMP-certified graders for trachomatous inflammation—follicular (TF) and trachomatous trichiasis (TT). Information on sources of household water and types of sanitation facilities used was collected through questioning and direct observation.

Results: The number of households enrolled per LGA ranged from 623 (Kware and Tangaza) to 2488 (Arewa). There have been marked reductions in the prevalence of TF and TT since baseline surveys were conducted in all 15 LGAs. Eight of the 15 LGAs have attained TF prevalences <5% in children, while 10 LGAs have attained TT prevalences <0.2% in persons aged ≥15 years. Between 49% and 96% of households had access to water for hygiene purposes within 1 km of the household, while only 10–59% had access to improved sanitation facilities.

Conclusion: Progress towards elimination of trachoma has been made in these 15 LGAs. Collaboration with water and sanitation agencies and community-based trichiasis surgery are still needed in order to eliminate trachoma by the year 2020.

Interventions to improve water supply and quality, sanitation and handwashing facilities in healthcare facilities, and their effect on healthcare-associated infections in low-income and middle-income countries: a systematic review and supplementary scoping review

INTRODUCTION

Healthcare-associated infections (HCAIs) are the most frequent adverse event compromising patient safety globally. Patients in healthcare facilities (HCFs) in low-income and middle-income countries (LMICs) are most at risk. Although water, sanitation and hygiene (WASH) interventions are likely important for the prevention of HCAIs, there have been no systematic reviews to date.

METHODS

As per our prepublished protocol, we systematically searched academic databases, trial registers, WHO databases, grey literature resources and conference abstracts to identify studies assessing the impact of HCF WASH services and practices on HCAIs in LMICs. In parallel, we undertook a supplementary scoping review including less rigorous study designs to develop a conceptual framework for how WASH can impact HCAIs and to identify key literature gaps.

RESULTS

Only three studies were included in the systematic review. All assessed hygiene interventions and included: a cluster-randomised controlled trial, a cohort study, and a matched case-control study. All reported a reduction in HCAIs, but all were considered at medium-high risk of bias. The additional 27 before-after studies included in our scoping review all focused on hygiene interventions, none assessed improvements to water quantity, quality or sanitation facilities. 26 of the studies reported a reduction in at least one HCAI. Our scoping review identified multiple mechanisms by which WASH can influence HCAI and highlighted a number of important research gaps.

CONCLUSIONS

Although there is a dearth of evidence for the effect of WASH in HCFs, the studies of hygiene interventions were consistently protective against HCAIs in LMICs. Additional and higher quality research is urgently needed to fill this gap to understand how WASH services in HCFs can support broader efforts to reduce HCAIs in LMICs.

PROSPERO REGISTRATION NUMBER

CRD42017080943.

A search for trachoma in Timor-Leste: no evidence to justify undertaking population-based prevalence surveys

Purpose

We sought evidence to justify undertaking population-based trachoma surveys in Timor-Leste, believing that in the absence of such evidence, the country could be categorized as not needing interventions to eliminate trachoma.

Methods

We undertook a systematic review of published literature on trachoma in Timor-Leste, with results updated to 28 April 2018. We also undertook a series of clinic- and field-based screening exercises, consisting of: (1) in October 2015, conjunctival examination of all children attending a school in Vila, Atauro Island; (2) from 1 November 2016 to 30 April 2017, examination for trichiasis, by specifically-trained frontline eye workers, of all individuals presenting to the ophthalmic clinics of six referral hospitals and five district eye clinics; and (3) house-to-house case searches in a total of 110 households, drawn from three communities that were reported by investigators from the 2016 Rapid Assessment of Avoidable Blindness (RAAB) to include residents with trachoma.

Results

Three RAABs (2005, 2009–2010, 2016) and two relevant published papers were identified. The 2016 RAAB reported one female subject to have been diagnosed with trachomatous corneal opacity. Re-examination of that individual revealed that she had ankyloblepharon, without evidence of trichiasis or entropion. No children on Atauro Island, no clinic attendees, and no individuals examined in the targeted house-to-house searches had any sign of trachoma.

Conclusion

Trachoma is very unlikely to be a public health problem in Timor-Leste. It would not be appropriate to incur the costs of conducting formal population-based trachoma prevalence surveys here.

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.

Prevalence of Trachoma and Access to Water and Sanitation in Benue State, Nigeria: Results of 23 Population-Based Prevalence Surveys

Purpose: We sought to determine the prevalence of trachoma in each local government area (LGA) of Benue State, Nigeria.

Methods: Two-stage cluster sampling was used to conduct a series of 23 population-based prevalence surveys. LGAs were the evaluation units surveyed. In each LGA, 25 households were selected in each of 25 clusters, and individuals aged 1 year and above resident in those households were invited to be examined for trachoma. Data on access to water and sanitation were also collected at household level.

Results: A total of 91,888 people were examined from among 93,636 registered residents across the 23 LGAs. The LGA-level prevalence of trachomatous inflammation—follicular (TF) in 1–9 year olds ranged from 0.3% to 5.3%. Two LGAs had TF prevalences of 5.0–9.9%. The LGA-level prevalence of trichiasis in ≥15-year-olds ranged from 0.0% to 0.35%. Access to improved drinking water sources ranged from 0% in Gwer West to 99% in Tarka, while access to improved sanitation ranged from 1% in Gwer West to 92% in Oturkpo.

Conclusion: There is a need for public health-level interventions against trachoma in three LGAs of Benue State.

Fluorometholone 0.1% as Ancillary Therapy for Trachomatous Trichiasis Surgery: Randomized Clinical Trial

PURPOSE

To assess the hypothesis that fluorometholone 0.1% eye drops are safe and effective as adjunctive therapy for trachomatous trichiasis (TT) surgery; determining the most promising dose.

DESIGN

Randomized, placebo-controlled, double-masked parallel dose-ranging clinical trial.

METHODS

Patients undergoing upper lid TT surgery at a rural Ethiopian hospital were randomized to fluorometholone 0.1% twice daily for 4 weeks, 4 times daily for 4 weeks, 4 times daily for 8 weeks, or matching frequency placebo in a 3:1:3:1:3:1 ratio for 1 eye. Randomization was stratified by TT severity (1-4 vs ≥5 lashes touching the globe). Safety outcomes (intraocular pressure [IOP] elevation, cataract, and other dose-limiting toxicities) and postoperative TT incidence were assessed over 1 year.

RESULTS

Subjects randomized were 39:13:39:13:38:13 in the respective groups, and 1 subject in the 8-weeks fluorometholone group was withdrawn. Of 154 subjects, 148 (96.1%) completed 1 year's follow-up. Among 76 eyes receiving fluorometholone 4 times daily, 1 developed IOP elevation ≥ 30 mm Hg (to 37 mm Hg) and 1 had an allergic reaction attributed to the study drug; each resolved upon drug cessation without sequelae. No cataract or other dose-limiting toxicity events occurred. Postoperative TT within 1 year occurred in 29.3% of placebo eyes vs 17.7%, 19.6%, and 23.2% among the respective fluorometholone groups (P = .29 comparing placebo vs all active treatments combined).

CONCLUSIONS

The results suggest fluorometholone 0.1% is likely to be safe and efficacious to reduce postoperative TT following TT surgery, and 1 drop twice daily for 4 weeks is the most promising dose. Confirmation in a full-scale clinical trial is needed before programmatic implementation.

Oral doxycycline for the prevention of postoperative trachomatous trichiasis in Ethiopia: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Trachomatous trichiasis is treated surgically to prevent sight loss. Unfavourable surgical outcomes remain a major challenge. We investigated the hypothesis that doxycycline might reduce the risk of postoperative trichiasis following surgery in patients with trachomatous trichiasis through anti-matrix metalloproteinase and anti-inflammatory activity.

METHODS

In this randomised, double-blind, placebo-controlled trial, adults (aged >18 years) with upper lid trachomatous trichiasis in association with tarsal conjunctive scarring were recruited through community-based screening and surgical outreach campaigns in Ethiopia. Individuals who had previously had eyelid surgery were excluded. Participants were randomly assigned (1:1), with random block sizes of four or six, to receive oral doxycycline (100 mg once a day) or placebo for 28 days immediately after trichiasis surgery. Randomisation was stratified by surgeon. Patients, investigators, surgeons, and all other study team members were masked to study group allocation and treatment. Participants were examined at 10 days, and 1, 6, and 12 months after surgery. The primary outcome was the cumulative proportion of individuals who developed postoperative trichiasis by 12 months. Primary analyses were done in all participants who attended at least one of the four follow-up assessments. Safety analyses were done in all participants who attended either the 10 day or 1 month follow-up assessments. This trial is registered with the Pan African Clinical Trials Registry, number PACTR201512001370307.

FINDINGS

Between Dec 21, 2015, and April 6, 2016, 1000 patients with trichiasis were enrolled and randomly assigned to treatment (499 patients to doxycycline, 501 patients to placebo). All but one participant attended at least one follow-up assessment. Thus, 999 participants were assessed for the primary outcome: 498 in the doxycycline group and 501 in the placebo group. By month 12, 58 (12%) of 498 patients in the doxycycline group and 62 (12%) of 501 patients in the placebo group had developed postoperative trichiasis (adjusted odds ratio 0·91, 95% CI 0·61 to 1·34, p=0·63), with a risk difference of -0·5% (-4·5% to 3·5%). Significantly more patients in the doxycycline group had an adverse event than in the placebo group (18 [4%] of 498 vs six [1%] of 501; odds ratio 3·09, 95% CI 1·21-7·84; p=0·02). The most frequent adverse events in the doxycycline group were gastritis symptoms (n=9), constipation (n=4), and diarrhoea (n=4).

INTERPRETATION

Doxycycline did not reduce the risk of postoperative trichiasis and is therefore not indicated for the improvement of outcomes following trachomatous trichiasis surgery. Surgical programmes should continue to make efforts to strengthen surgical training and supervision to improve outcomes.

FUNDING

The Wellcome Trust.

Sanitation and water supply coverage thresholds associated with active trachoma: Modeling cross-sectional data from 13 countries

BACKGROUND

Facial cleanliness and sanitation are postulated to reduce trachoma transmission, but there are no previous data on community-level herd protection thresholds. We characterize associations between active trachoma, access to improved sanitation facilities, and access to improved water sources for the purpose of face washing, with the aim of estimating community-level or herd protection thresholds.

METHODS AND FINDINGS

We used cluster-sampled Global Trachoma Mapping Project data on 884,850 children aged 1-9 years from 354,990 households in 13 countries. We employed multivariable mixed-effects modified Poisson regression models to assess the relationships between water and sanitation coverage and trachomatous inflammation-follicular (TF). We observed lower TF prevalence among those with household-level access to improved sanitation (prevalence ratio, PR = 0.87; 95%CI: 0.83-0.91), and household-level access to an improved washing water source in the residence/yard (PR = 0.81; 95%CI: 0.75-0.88). Controlling for household-level water and latrine access, we found evidence of community-level protection against TF for children living in communities with high sanitation coverage (PR80-90% = 0.87; 95%CI: 0.73-1.02; PR90-100% = 0.76; 95%CI: 0.67-0.85). Community sanitation coverage levels greater than 80% were associated with herd protection against TF (PR = 0.77; 95%CI: 0.62-0.97)-that is, lower TF in individuals whose households lacked individual sanitation but who lived in communities with high sanitation coverage. For community-level water coverage, there was no apparent threshold, although we observed lower TF among several of the higher deciles of community-level water coverage.

CONCLUSIONS

Our study provides insights into the community water and sanitation coverage levels that might be required to best control trachoma. Our results suggest access to adequate water and sanitation can be important components in working towards the 2020 target of eliminating trachoma as a public health problem.

A review on ocular findings in mouse lemurs: potential links to age and genetic background

Mouse lemurs, the world's smallest primates, inhabit forests in Madagascar. They are nocturnal, arboreal and dependent on vision for their everyday lives. In the last decades, the grey mouse lemur became increasingly important for biomedical research, in particular aging research. Experiments which require the combination of visual fitness and old age consequently depend on a solid knowledge of ocular pathologies. Although ocular diseases in mouse lemurs have been described as being common, they have not received much attention so far. Yet it is important to know when and why ocular diseases in captive mouse lemurs may occur. This review aims to provide a comprehensive overview of known ocular findings in mouse lemurs. It summarizes the frequency of ocular findings in captive mouse lemur colonies and points to their likely causes and treatment options based on the evidence available from other animals and humans. In addition, it shall be discussed whether age or genetic background may affect their development. This review may be used as a reference for future studies which require an assessment of visual performance in mouse lemurs and help to evaluate observed clinical signs and ocular diseases. Furthermore, the high incidence of specific diseases may provide new perspectives and set the groundwork for a new animal model for ocular research.

Posterior lamellar versus bilamellar tarsal rotation surgery for trachomatous trichiasis in Ethiopia: a randomised controlled trial

BACKGROUND

Eyelid surgery is done to correct trachomatous trichiasis to prevent blindness. However, recurrent trichiasis is frequent. Two procedures are recommended by WHO and are in routine practice: bilamellar tarsal rotation (BLTR) and posterior lamellar tarsal rotation (PLTR). This study was done to identify which procedure gives the better results.

METHODS

A randomised, controlled, single masked clinical trial was done in Ethiopia. Participants had upper lid trachomatous trichiasis with one or more eyelashes touching the eye or evidence of epilation, in association with tarsal conjunctival scarring. Exclusion criteria were age less than 18 years, recurrent trichiasis after previous surgery, hypertension, and pregnancy. Participants were randomly assigned (1:1) to either BLTR or PLTR surgery, stratified by surgeon. The sequences were computer-generated by an independent statistician. Surgery was done in a community setting following WHO guidelines. Participants were examined at 6 months and 12 months by assessors masked to allocation. The primary outcome was the cumulative proportion of individuals who developed recurrent trichiasis by 12 months. Primary analyses were by modified intention to treat. The intervention effect was estimated by logistic regression, controlled for surgeon as a fixed effect in the model. The trial is registered with the Pan African Clinical Trials Registry (number PACTR201401000743135).

FINDINGS

1000 participants with trichiasis were recruited, randomly assigned, and treated (501 in the BLTR group and 499 in the PLTR group) between Feb 13, 2014, and May 31, 2014. Eight participants were not seen at either 6 month or 12 month follow-up visits and were excluded from the analysis: three from the PLTR group and five from the BLTR group. The follow-up rate at 12 months was 98%. Cumulative recurrent trichiasis by 12 months was more frequent in the BLTR group than in the PLTR group (110/496 [22%] vs 63/496 [13%]; adjusted odds ratio [OR] 1·96 [95% CI 1·40-2·75]; p=0·0001), with a risk difference of 9·50% (95% CI 4·79-14·16).

INTERPRETATION

PLTR surgery was superior to BLTR surgery for management of trachomatous trichiasis, and could be the preferred procedure for the programmatic management of trachomatous trichiasis.

FUNDING

The Wellcome Trust.