The possibility of eliminating blinding trachoma

The elimination of trachoma as a public health problem in Togo: Successes and challenges

BACKGROUND

As of May 2022, 15 countries have declared that they have reached their trachoma elimination targets, but only 13 of them, including Togo, have been validated by the World Health Organization as having eliminated the disease as a public health problem. The aim of this study was to describe the broad interventions that have supported the elimination of trachoma as a public health problem in Togo from its inception in 2006 to the validation of its elimination in 2022.

METHOD

A review and compilation of data and information contained in the country's submission to World Health Organization for validation of trachoma elimination as a public health problem was conducted. Data from national and local surveillance systems and reports on actions taken after achieving the elimination target were also included.

RESULTS

Togo has achieved the elimination of trachoma as a public health problem by 2022. The prevalence of follicular trachoma among children aged 1-9 years is <5% in all nationally defined administrative units suspected of having trachoma after stopping mass treatment for at least 2 years. The prevalence of trichiasis among persons aged 15 years and older is less than 0.2% in all administrative units previously endemic for trachoma and evidence of the ability to manage incident cases of emerging trichiasis in the community has been demonstrated. The key of the success in the elimination process was primarily the political commitment of the health authorities with financial and technical support from various international organizations.

CONCLUSION

The elimination of trachoma as a public health problem in Togo is a real success story that can serve as an example for the elimination of other neglected tropical diseases in Africa. But regular monitoring and surveillance is essential to avoid the re-emergence of such disease in the country.

The Weight of Evidence From Electrophysiology, Observational, and Cardiovascular End Point Studies Demonstrates the Safety of Azithromycin

Increased use of azithromycin (AZ) in treating infections associated with coronavirus disease 2019 (COVID-19) and reports of increased incidence of prolonged corrected QT (QTc) interval associated with AZ used with hydroxychloroquine prompted us to review the latest evidence in the literature, present additional analyses of human cardiovascular (CV) electrophysiology studies, and to describe sequential steps in research and development that were undertaken to characterize the benefit-risk profile of AZ. Combined QTc findings from electrocardiograms taken during oral and i.v. pharmacokinetic-pharmacodynamic studies of AZ suggest that clinically meaningful QTc prolongation is unlikely. Findings from several observational studies were heterogeneous and not as consistent as results from at least two large randomized controlled trials (RCTs). The QTc findings presented and observational data from studies with large numbers of events are not consistent with either a proarrhythmic action of AZ or an increase in frequency of CV deaths. Well-powered RCTs do not suggest a presence of increased risk of CV or sudden cardiac death after short-term or protracted periods of AZ usage, even in patients at higher risk from pre-existing coronary disease.

Viability PCR shows that non-ocular surfaces could contribute to transmission of Chlamydia trachomatis infection in trachoma

Background

The presence of Chlamydia trachomatis (Ct) DNA at non-ocular sites suggests that these sites may represent plausible routes of Ct transmission in trachoma. However, qPCR cannot discriminate between DNA from viable and non-viable bacteria. Here we use a propodium monoazide based viability PCR to investigate how long Ct remains viable at non-ocular sites under laboratory-controlled conditions.

Methods

Cultured Ct stocks (strain A2497) were diluted to final concentrations of 1000, 100, 10 and 1 omcB copies/μL and applied to plastic, woven mat, cotton cloth and pig skin. Swabs were then systemically collected from each surface and tested for the presence Ct DNA using qPCR. If Ct DNA was recovered, Ct viability was assessed over time by spiking multiple areas of the same surface type with the same final concentrations. Swabs were collected from each surface at 0, 2, 4, 6, 8 and 24 hours after spiking. Viability PCR was used to determine Ct viability at each timepoint.

Results

We were able to detect Ct DNA on all surfaces except the woven mat. Total Ct DNA remained detectable and stable over 24 hours for all concentrations applied to plastic, pig skin and cotton cloth. The amount of viable Ct decreased over time. For plastic and skin surfaces, only those where concentrations of 100 or 1000 omcB copies/μL were applied still had viable loads detectable after 24 hours. Cotton cloth showed a more rapid decrease and only those where concentrations of 1000 omcB copies/μL were applied still had viable DNA detectable after 24 hours.

Conclusion

Plastic, cotton cloth and skin may contribute to transmission of the Ct strains that cause trachoma, by acting as sites where reservoirs of bacteria are deposited and later collected and transferred mechanically into previously uninfected eyes.

Trachoma elimination efforts are hampered by limited understanding of Ct transmission routes. We have recently demonstrated the presence of Ct DNA at non-ocular sites in individuals living in households in Ethiopia where at least one resident had an ocular Ct infection detectable by quantitative PCR (qPCR). Ct DNA was most frequently detected on faces, hands and clothing, being found in such locations in 10–16% of samples tested. However, qPCR cannot discriminate between DNA from viable and non-viable organisms, and potentially misinform our understanding of Ct transmission routes. In this study, we used a propidium monoazide based viability PCR to investigate how long Ct remains viable on non-ocular sites by spiking different surfaces including pig skin, plastic and cotton cloth. These surfaces mimic non-ocular sites previously found to be positive for Ct DNA using standard qPCR. The results of our study show that viable Ct DNA could be recovered from plastic, cotton cloth and skin surfaces for up to 24 hours suggesting that these surfaces a role in ocular Ct transmission.

Detecting extra-ocular Chlamydia trachomatis in a trachoma-endemic community in Ethiopia: Identifying potential routes of transmission

BACKGROUND

Trachoma elimination efforts are hampered by limited understanding of Chlamydia trachomatis (Ct) transmission routes. Here we aimed to detect Ct DNA at non-ocular sites and on eye-seeking flies.

METHODS

A population-based household survey was conducted in Oromia Region, Ethiopia. Ocular and non-ocular (faces, hands, clothing, water containers and sleeping surfaces) swabs were collected from all individuals. Flies were caught from faces of children. Flies, ocular swabs and non-ocular swabs were tested for Ct by quantitative PCR.

RESULTS

In total, 1220 individuals in 247 households were assessed. Active trachoma (trachomatous inflammation-follicular) and ocular Ct were detected in 10% and 2% of all-ages, and 21% and 3% of 1-9-year-olds, respectively. Ct was detected in 12% (95% CI:8-15%) of tested non-ocular swabs from ocular-positive households, but in none of the non-ocular swabs from ocular-negative households. Ct was detected on 24% (95% CI:18-32%) of flies from ocular-positive households and 3% (95% CI:1-6%) of flies from ocular-negative households.

CONCLUSION

Ct DNA was detected on hands, faces and clothing of individuals living in ocular-positive households suggesting that this might be a route of transmission within Ct infected households. In addition, we detected Ct on flies from ocular-positive households and occasionally in ocular-negative households suggesting that flies might be a vector for transmission within and between Ct infected and uninfected households. These potential transmission routes may need to be simultaneously addressed to suppress transmission.

International Vision Care: Issues and Approaches

Globally, 32.4 million individuals are blind and 191 million have moderate or severe visual impairment (MSVI); 80% of cases of blindness and MSVI are avoidable. However, great efforts are needed to tackle blindness and MSVI, as eye care in most places is delivered in isolation from and without significant integration with general health sectors. Success stories, including control of vitamin A deficiency, onchocerciasis, and trachoma, showed that global partnerships, multisectoral collaboration, public-private partnerships, corporate philanthropy, support from nongovernmental organizations-both local and international-and governments are responsible for the success of these programs. Hence, the World Health Organization's universal eye health global action plan for 2014-2019 has a goal of reducing the public health problem of blindness and ensuring access to comprehensive eye care; the plan aims to integrate eye health into health systems, thus providing universal eye health coverage (UEHC). This article discusses the challenges faced by low- and middle-income countries in strengthening the six building blocks of the health system. It discusses how the health systems in these countries need to be geared toward tackling the issues of emerging noncommunicable eye diseases, existing infectious diseases, and the common causes of blindness and visual impairment, such as cataract and refractive error. It also discusses how some of the comprehensive eye care models in the developing world have addressed these challenges. Moving ahead, if we are to achieve UEHC, we need to develop robust, sustainable, good-quality, comprehensive eye care programs throughout the world, focusing on the areas of greatest need. We also need to develop public health approaches for more complex problems such as diabetic retinopathy, glaucoma, childhood blindness, corneal blindness, and low vision. There is also a great need to train high-level human resources of all cadres in adequate numbers and quality. In addition to this, we need to exploit the benefits of modern technological innovations in information, communications, biomedical technology, and other domains to enhance quality of, access to, and equity in eye care.

Elimination of trachoma as a public health problem in Ghana: Providing evidence through a pre-validation survey

Background

In order to achieve elimination of trachoma, a country needs to demonstrate that the elimination prevalence thresholds have been achieved and then sustained for at least a two-year period. Ghana achieved the thresholds in 2008, and since 2011 has been implementing its trachoma surveillance strategy, which includes community and school screening for signs of follicular trachoma and trichiasis, in trachoma-endemic districts. In 2015–2016, the country conducted a district level population-based survey to validate elimination of trachoma as a public health problem.

Methods

As per WHO recommendations, a cross-sectional survey, employing a two-stage cluster random sampling methodology, was used across 18 previously trachoma endemic districts (evaluation units (EUs) in the Upper West and Northern Regions of Ghana. In each EU 24 villages were selected based on probability proportional to estimated size. A minimum of 40 households were targeted per village and all eligible residents were examined for clinical signs of trachoma, using the WHO simplified grading system. The number of trichiasis cases unknown to the health system was determined. Household environmental risk factors for trachoma were also assessed.

Results

Data from 45,660 individuals were examined from 11,099 households across 18 EUs, with 27,398 (60.0%) children aged 1–9 years and 16,610 (36.4%) individuals 15 years and above All EUs had shown to have maintained the WHO elimination threshold for Trachomatous inflammation-Follicular (TF) (<5.0% prevalence) in children aged 1–9 years old. The EU TF prevalence in children aged 1–9 years old ranged from between 0.09% to 1.20%. Only one EU (Yendi 0.36%; 95% CI: 0.0–1.01) failed to meet the WHO TT elimination threshold (< 0.2% prevalence in adults aged 15 and above). The EU prevalence of trichiasis (TT) unknown to the health system in adults aged ≥15 years, ranged from 0.00% to 0.36%. In this EU, the estimated TT backlog is 417 All TT patients identified in the study, as well as through on-going surveillance efforts will require further management. A total of 75.9% (95% CI 72.1–79.3, EU range 29.1–92.6) of households defecated in the open but many households had access to an improved water source 75.9% (95%CI: 71.5–79.8, EU range 47.4–90.1%), with 45.5% (95% CI 41.5–49.7%, EU range 28.4–61.8%) making a round trip of water collection < 30 minutes.

Conclusion

The findings from this survey indicate elimination thresholds have been maintained in Ghana in 17 of the 18 surveyed EUs. Only one EU, Yendi, did not achieve the TT elimination threshold. A scheduled house-by-house TT case search in this EU coupled with surgery to clear the backlog of cases is necessary in order for Ghana to request validation of elimination of trachoma as a public health problem.

Trachoma is an eye disease caused by an infection with Chlamydia trachomatis. It is the leading cause of blindness due to infection globally. However, trachoma is both treatable and preventable through antibiotics and surgery, and may be preventable with basic hygiene improvements. Thus, the Surgery, Antibiotics, Facial cleanliness and Environmental modification (SAFE) strategy is endorsed by the World Health Organization for the implementation of interventions. Trachoma is a progressive disease. Clinically active trachoma, the follicular (trachomatous-inflammation follicular (TF)) and intense (trachomatous- inflammation intense (TI)) phases are most common in children aged 1–9 years old while complications such as in turned lashes and loss of vision are found mainly in adults. Globally, the disease is earmarked for elimination as a public health problem by the year 2020. In Ghana, studies conducted in 2000–2003 identified trachoma as endemic in the Upper West and Northern regions and by 2004 the elimination strategy based on Surgery, Antibiotics treatment, Face washing and Environmental improvement, was being implemented in all 18 districts in the two regions. Surveys conducted in 2008 indicated that the strategy had been successful with reduction of clinically active trachoma to elimination levels in all 18 districts. Ghana implemented a post-elimination surveillance phase from 2011–2014 and conducted a formal prevalence survey in 2015–2016 using WHO standard grading methodologies, the results of which are presented here. The results showed that TF prevalence was below the 5% elimination target in children aged 1–9 years old in all 18 districts, while TT was below 2 cases in every 1000 persons aged 15 and above in all 18 endemic districts except one (Yendi district). Ghana has put in place a TT case search of all persons 15 years and above in the Yendi district to identify persons with the complications and offer surgery to them. The outcomes of these investigations will enable Ghana to provide evidence for WHO dossier submission, to acknowledge validation of elimination of trachoma as public health problem.

The added value of water, sanitation, and hygiene interventions to mass drug administration for reducing the prevalence of trachoma: a systematic review examining

Trachoma is the leading cause of infectious blindness worldwide. The SAFE strategy, the World Health Organization-recommended method to eliminate blinding trachoma, combines developments in water, sanitation, surgery, and antibiotic treatment. Current literature does not focus on the comprehensive effect these components have on one another. The present systematic review analyzes the added benefit of water, sanitation, and hygiene education interventions to preventive mass drug administration of azithromycin for trachoma. Trials were identified from the PubMed database using a series of search terms. Three studies met the complete criteria for inclusion. Though all studies found a significant change in reduction of active trachoma prevalence, the research is still too limited to suggest the impact of the “F” and “E” components on trachoma prevalence and ultimately its effects on blindness.

Active trachoma and associated risk factors among children in Baso Liben District of East Gojjam, Ethiopia

Background

Trachoma is the leading cause of preventable blindness worldwide. It is common in areas where the people are socio-economically deprived. The aim of this study was to assess active trachoma and associated risk factors among children 1–9 years in East Gojjam.

Methods

Community-based cross-sectional study was conducted in Baso Liben District from February to April 2012. A two-stage random cluster-sampling technique was employed and all children 1–9 years old from each household were clinically assessed for trachoma based on simplified WHO 1983 classification. Data were collected by using semi-structured interview, pre-tested questionnaire and observation. The data were entered and analyzed using SPSS version 16 statistical package.

Results

From a total of 792 children screened for trachoma (of which 50.6% were girls), the overall prevalence of active trachoma was 24.1% consisting of only 17.2% [95% CI: 14.8, 20.1] TF and 6.8% TI. There were variations among children living in low land (29.3%) and in medium land (21.4%). In multivariate analysis, low monthly income (AOR = adjusted odds ratio) 2.98; 95% CI (confidence interval): 1.85-7.85), illiterate family (AOR = 5.18; 95% CI: 2.92-9.17); unclean face (AOR = 18.68; 95% CI: 1.98-175.55); access to water source (AOR = 2.01; 95% CI: 1.27-3.15); less than 20 liters of water use (AOR = 4.88; 95% CI: 1.51-15.78); not using soap for face washing (AOR = 5.84; 95% CI: 1.98-17.19); not using latrine frequently (AOR = 1.75; 95% CI: 0.01-0.42); density of flies (AOR = 3.77; 95% CI: 2.26-6.29); less knowledgeable family (AOR = 3.91; 95% CI: 2.40-6.38) and average monthly income (AOR = 2.98; 95% CI: 1.85-7.85) were found independently associated with trachoma.

Conclusion

Active trachoma is a major public problem among 1–9 years children and significantly associated with a number of risky factors. Improvement in awareness of facial hygiene, environmental conditions, mass antibiotic distribution and health education on trachoma transmission and prevention should be strengthened in the District.

Azithromycin blocks autophagy and may predispose cystic fibrosis patients to mycobacterial infection

Azithromycin is a potent macrolide antibiotic with poorly understood antiinflammatory properties. Long-term use of azithromycin in patients with chronic inflammatory lung diseases, such as cystic fibrosis (CF), results in improved outcomes. Paradoxically, a recent study reported that azithromycin use in patients with CF is associated with increased infection with nontuberculous mycobacteria (NTM). Here, we confirm that long-term azithromycin use by adults with CF is associated with the development of infection with NTM, particularly the multi-drug-resistant species Mycobacterium abscessus, and identify an underlying mechanism. We found that in primary human macrophages, concentrations of azithromycin achieved during therapeutic dosing blocked autophagosome clearance by preventing lysosomal acidification, thereby impairing autophagic and phagosomal degradation. As a consequence, azithromycin treatment inhibited intracellular killing of mycobacteria within macrophages and resulted in chronic infection with NTM in mice. Our findings emphasize the essential role for autophagy in the host response to infection with NTM, reveal why chronic use of azithromycin may predispose to mycobacterial disease, and highlight the dangers of inadvertent pharmacological blockade of autophagy in patients at risk of infection with drug-resistant pathogens.

Health Psychology

The chapter draws parallels and contrasts between the study of health in North American and other industrialized countries and health of people living in developing countries, which comprise 80% of the world’s population. Lessons are provided for three common health problems where psychologists play a major role within multidisciplinary teams. The lessons use published journal articles, web sites of international organizations, and the author’s personal experiences living and working in developing countries. One topic concerns the large number of women who unnecessarily die in childbirth and the non-medical reasons. The second is environmental health, which includes sources of clean water, waste disposal, and personal hygiene. Solving this problem requires behavior change. The third concerns child hunger and its disabling effects on cognitive development. The focus of this chapter is on examining the health problem within context and identifying solutions that work and do not work. Background is provided for the novice, so students learn the larger picture into which these issues fit, and how to apply the same analysis to other health problems.

Programmes, partnerships, and governance for elimination and control of neglected tropical diseases

Neglected tropical diseases represent one of the most serious burdens to public health. Many can be treated cost-effectively, yet they have been largely ignored on the global health policy agenda until recently. In this first paper in the Series we review the fragmented structure of elimination and control programmes for these diseases, starting with the ambiguous definition of a neglected tropical disease. We describe selected international control initiatives and present their effect, governance arrangements, and financing mechanisms, including substantial drug-donation programmes. We also discuss efforts to exploit shared features of these diseases by integration of selected control activities within countries, thus creating economies of scope. Finally we address the challenges, resulting from the diversity of disease control approaches and governance structures-both nationally and internationally-and provide some suggestions for the way forward.

Neglected tropical diseases in sub-saharan Africa: review of their prevalence, distribution, and disease burden

The neglected tropical diseases (NTDs) are the most common conditions affecting the poorest 500 million people living in sub-Saharan Africa (SSA), and together produce a burden of disease that may be equivalent to up to one-half of SSA's malaria disease burden and more than double that caused by tuberculosis. Approximately 85% of the NTD disease burden results from helminth infections. Hookworm infection occurs in almost half of SSA's poorest people, including 40-50 million school-aged children and 7 million pregnant women in whom it is a leading cause of anemia. Schistosomiasis is the second most prevalent NTD after hookworm (192 million cases), accounting for 93% of the world's number of cases and possibly associated with increased horizontal transmission of HIV/AIDS. Lymphatic filariasis (46-51 million cases) and onchocerciasis (37 million cases) are also widespread in SSA, each disease representing a significant cause of disability and reduction in the region's agricultural productivity. There is a dearth of information on Africa's non-helminth NTDs. The protozoan infections, human African trypanosomiasis and visceral leishmaniasis, affect almost 100,000 people, primarily in areas of conflict in SSA where they cause high mortality, and where trachoma is the most prevalent bacterial NTD (30 million cases). However, there are little or no data on some very important protozoan infections, e.g., amebiasis and toxoplasmosis; bacterial infections, e.g., typhoid fever and non-typhoidal salmonellosis, the tick-borne bacterial zoonoses, and non-tuberculosis mycobaterial infections; and arboviral infections. Thus, the overall burden of Africa's NTDs may be severely underestimated. A full assessment is an important step for disease control priorities, particularly in Nigeria and the Democratic Republic of Congo, where the greatest number of NTDs may occur.

Randomized trial of high dose azithromycin compared to standard dosing for children with severe trachoma in Tanzania

BACKGROUND

Children with a heavy load of C. trachomatis infection may continue to be infected following a single dose of 20 mg/kg of azithromycin. We compared the C. trachomatis infection rates at six weeks post-treatment of children randomized to 30 mg/kg single dose of azithromycin versus 20 mg/kg single dose of azithromycin.

METHODS

Ninety-nine children with severe trachoma (defined as either trachoma intense or follicular trachoma with ten or more follicles) were enrolled and randomly assigned. Baseline data on age, sex, and trachoma status was obtained, and swabs for determination of C. trachomatis were taken. Dosing was weight-based and observed. Children were followed up at six weeks for trachoma and infection. The laboratory was masked to treatment assignment.

RESULTS

Both groups experienced reductions in infection and in severe trachoma. Twelve percent of the 20 mg/kg group were PCR positive at 6 weeks, compared with 69% at baseline, an 82% reduction (p-value < .001). In the 30 mg/kg group, 15% were infected, compared with 62% at baseline, a 76% reduction (p < .001). The rate of infection comparing treatment groups was not significantly different at 6 weeks (p = 0.71). Analyses on children who were infected at baseline showed those remaining positive at six weeks were 18%, and 14% in the standard and high dose groups, respectively.

CONCLUSION

Increasing the single dose of azithromycin to 30 mg/kg in children with severe trachoma did not result in significantly less infection at six weeks post-treatment compared to 20 mg/kg.

When can antibiotic treatments for trachoma be discontinued? Graduating communities in three African countries

BACKGROUND

Repeated mass azithromycin distributions are effective in controlling the ocular strains of chlamydia that cause trachoma. However, it is unclear when treatments can be discontinued. Investigators have proposed graduating communities when the prevalence of infection identified in children decreases below a threshold. While this can be tested empirically, results will not be available for years. Here we use a mathematical model to predict results with different graduation strategies in three African countries.

METHODS

A stochastic model of trachoma transmission was constructed, using the parameters with the maximum likelihood of obtaining results observed from studies in Tanzania (with 16% infection in children pre-treatment), The Gambia (9%), and Ethiopia (64%). The expected prevalence of infection at 3 years was obtained, given different thresholds for graduation and varying the characteristics of the diagnostic test.

RESULTS

The model projects that three annual treatments at 80% coverage would reduce the mean prevalence of infection to 0.03% in Tanzanian, 2.4% in Gambian, and 12.9% in the Ethiopian communities. If communities graduate when the prevalence of infection falls below 5%, then the mean prevalence at 3 years with the new strategy would be 0.3%, 3.9%, and 14.4%, respectively. Graduations reduced antibiotic usage by 63% in Tanzania, 56% in The Gambia, and 11% in Ethiopia.

CONCLUSION

Models suggest that graduating communities from a program when the infection is reduced to 5% is a reasonable strategy and could reduce the amount of antibiotic distributed in some areas by more than 2-fold.

Evaluation of three years of the SAFE strategy (Surgery, Antibiotics, Facial cleanliness and Environmental improvement) for trachoma control in five districts of Ethiopia hyperendemic for trachoma

Trachoma surveys were conducted at baseline in five districts of Amhara National Regional State, Ethiopia (7478 participants in 1096 households) and at 3-year evaluation (5762 participants in 1117 households). Uptake of SAFE was assessed with programme monitoring data and interviews, and children (1-6 years) were swabbed for detection of ocular Chlamydia. At evaluation, 23,933 people had received trichiasis surgery; 93% of participants reported taking azithromycin at least once; 67% of household respondents (range 46-93) reported participation in trachoma health education; and household latrine coverage increased from 2% to 34%. In children aged 1-9 years percentage decline, by district, for outcomes was: 32% (95% CI 19-48) to 88% (95% CI 83-91) for trachomatous inflammation-follicular (TF); 87% (95% CI 83-91) to 99% (95% CI 97-100) for trachomatous inflammation-intense (TI); and 31% increase (95% CI -42 to -19) to 89% decrease (95% CI 85-93) for unclean face; and in adults percentage decline in trichiasis was 45% (95% CI -13 to 78) to 92% (95% CI 78-96). Overall prevalence of swabs positive for ocular Chlamydia was 3.1%. Although there were substantial reductions in outcomes in children and adults, the presence of ocular Chlamydia and TF in children suggests ongoing transmission. Continued implementation of SAFE is warranted.

Prevalence of Trachoma-Related Trichiasis and Corneal Opacity in Rural Myanmar

OBJECTIVE

To describe the prevalence of trachomatous trichiasis and corneal opacity (CO) within central Myanmar.

DESIGN

Population-based cross-sectional ophthalmic survey.

PARTICIPANTS

Random, stratified, cluster sampling of the inhabitants > or =40 years of age from villages in the Meiktila District was performed; 2481 eligible participants were identified and 2076 participated in the study.

METHODS

Visual acuity was measured using an E Snellen chart at 6 meters. Lid, ocular surface, and anterior segment examinations were performed at the slit lamp.

MAIN OUTCOME MEASURES

Trachoma was graded as trachomatous trichiasis (TT) or CO according to the World Health Organization grading system.

RESULTS

The population prevalence of trachoma (TT and CO) was 2.6% (95% confidence interval [CI]. 1.67%-3.42%). For every 1-year increase in age, the odds of trachoma increased by 5.3% (95% CI, 4.9%-5.7%). There was no significant effect of gender on the prevalence of trachoma (P = 0.5). No formal schooling was a strong predictor of trachoma (odds ratio, [OR], 4.9; 95% CI, 3.9-6.1), and having <3 children in the house was protective (OR, 0.75; 95% CI, 0.61-0.93); however, neither occupation nor the number of people in a household had an effect on trachoma.

CONCLUSIONS

The prevalence of blinding trachoma in central Myanmar remains relatively low. This is a tribute to the success of the Burma Trachoma Control Program and demonstrates the need for such a program to remain an integral part of public health care and community health services to further diminish the prevalence of this condition. This will be facilitated by a focus on trachoma risk factors and further research into the prevalence of inflammatory trachoma within the pediatric population.

Trachoma: Ancient scourge, disease elimination, and future research

Realistically, global elimination of trachoma could not have been considered until the maturation of innovation and public will that converged with the formation of both the Alliance for the Global Elimination of Trachoma by the year 2020 (GET2020) in 1997 and the public-private partnership, the International Trachoma Initiative (ITI) in 1998. Public-private partnerships are cross-sector collaborations that bring heterogeneous capabilities together to work on difficult problems for which the individual partners share common goals. The work of the ITI and partners to date demonstrates that the SAFE strategy reviewed in this article can work, and that it will revolutionize the control of blinding trachoma. Programs working to eliminate trachoma can achieve the GET2020 goals through expanded partnerships, commitment, and research on program integration into evolving health systems.

Comparison of an rRNA-based and DNA-based nucleic acid amplification test for the detection of Chlamydia trachomatis in trachoma

BACKGROUND/AIM

The World Health Organisation (WHO) hopes to achieve global elimination of trachoma, still the leading cause of preventable blindness worldwide, in part through mass antibiotic treatment. DNA-based nucleic acid amplification tests (NAATs) are currently used to evaluate the success of treatment programmes by measuring the prevalence of C trachomatis infection. Some believe that newer ribosomal RNA (rRNA)-based tests may be much more sensitive since bacterial rRNA is present in amounts up to 10 000 times that of genomic DNA. Others believe that rRNA-based tests are instead less sensitive but more specific, due to the presence of dead or subviable organisms that the test may not detect. This study compares an rRNA-based test to a DNA-based test for the detection of ocular C trachomatis infection in children living in trachoma-endemic villages.

METHODS

An rRNA-based amplification test and DNA-based polymerase chain reaction (PCR) were performed on swab specimens taken from the right upper tarsal conjunctiva of 56 children aged 0-10 years living in two villages in Amhara, Ethiopia.

RESULTS

The rRNA-based test detected ocular C trachomatis infection in 35 (63%) subjects compared with 22 (39%) detected by PCR (McNemar's test, p = 0.0002). The rRNA-based test gave positive results for all subjects that were positive by PCR, and also detected infection in 13 (23%) additional subjects.

CONCLUSION

The rRNA-based test appears to have significantly greater sensitivity than PCR for the detection of ocular chlamydial infection in children in trachoma-endemic villages. Using the rRNA-based test, we may be able to detect infection that was previously missed with PCR. Past studies using DNA-based tests to assess prevalence of infectious trachoma following antibiotic treatment may have underestimated the true prevalence of infection.

Projected benefits from integrating NTD programs in sub-Saharan Africa

The integration of preventive chemotherapy programs (PCPs) targeting multiple neglected tropical diseases (NTDs) with similar strategic approaches offers opportunities for enhanced cost-effectiveness. To estimate the potential cost savings and health outcomes of integrated programs, the data available for five NTDs (lymphatic filariasis, onchocerciasis, intestinal helminthiasis, schistosomiasis and trachoma) can be used to define eligible target populations, the probable overlap of at-risk populations, and the cost per person treated in stand-alone and integrated programs. If all targets for 2006 in sub-Saharan Africa are met, then savings of 26-47% can be projected from such integration (a cost of US dollar 58-81 million versus dollar 110 million for stand-alone PCPs). These first estimates can be refined as empirical data become available from integrated PCPs in the future.

Impact of face washing and environmental improvement on reduction of active trachoma in Vietnam-a public health intervention study

PURPOSE

A public health intervention study in Vietnam was conducted between 2002 and 2005 to assess the impact of improved water and sanitation facilities and increased awareness about active trachoma in the community.

METHODS

In My Thon village (MT), all four components of the SAFE strategy were implemented. In Xom Ngoai village (XN), only the S & A components of the trachoma control strategy were implemented. The villagers improved water and sanitation facilities in MT. Women's Union and school authorities assisted in increasing awareness in the community. Ophthalmologists examined the residents for trachoma. The decline in active trachoma and other water-related diseases was determined by pre- and post-intervention assessments. The impact of the differential F & E strategy on two villages was evaluated.

RESULTS

The active trachoma prevalence in MT (SAFE) and XN (SA) at baseline was 13.3% and 10.2%, respectively. In two years, the masons constructed or improved 281 double-vault and three septic tank latrines, 241 bathrooms, 273 dug wells and 252 water tanks in MT. The prevalence in MT (SAFE) & XN (SA) after two years was 1.4% and 6.7%, respectively. The additional decline of active trachoma due to the differential F & E strategy among children under the age of 15 was 6.8%. The F & E strategy was responsible for 58.7% of the decline at all ages and 37.4% in children under the age of 15. Knowledge of the prevention of trachoma had improved in two years. However, the attitude towards and practice of trachoma control were not different in the two villages.

CONCLUSIONS

'F' & 'E' implementation made a significant contribution to the reduction of active trachoma. Community participation and collaborative efforts of partners are crucial. The indicators used to monitor F & E strategies are interrelated and therefore should be evaluated together.

New initiatives against Africa's worms

Since 1999, the funding available for the control of diseases of poverty (neglected diseases) has increased mainly due to leverage resulting from donations by the Bill and Melinda Gates Foundation and loans from the World Bank. Many countries have embarked on control programmes on a national scale due to drug donations by pharmaceutical companies through vertical programmes. The Schistosomiasis Control Initiative has expanded its operations to cover six countries in sub-Saharan Africa, but overlap of treatments between different vertical programmes is now a reality, and so care is needed to ensure that too many different drugs are not given together. Dialogue between programme managers has increased, and integration of some programmes may offer chances of synergy.

"Rapid-impact interventions": how a policy of integrated control for Africa's neglected tropical diseases could benefit the poor

Controlling seven tropical infections in Africa would cost just 40 cents per person per year, and would permanently benefit hundreds of millions of people.

Can blinding trachoma be eliminated by 20/20?

Trachoma is the leading cause of preventable blindness in the world today. Long ago eliminated in North America and Europe, the disease is almost unknown, and indeed forgotten, in the West. Nevertheless, it continues to wreak havoc in the poorest parts of Africa, Asia, and other areas throughout the world. The World Health Organization (WHO) estimates that there are currently 7.6 million people who are visually impaired due to trachoma, and 84 million people with active infections. In 1998, WHO passed a resolution calling for member states to take action to eliminate blinding trachoma by the year 2020. The scale of what must be accomplished in order to reach this goal is daunting. However, the work of the International Trachoma Initiative together with national governments as well as other organizations in applying the WHO-recommended SAFE strategy for trachoma control has produced critical successes in challenging settings. This paper gives a brief history and description of trachoma, explains treatment options and the SAFE strategy, and discusses successes from two trachoma control programmes as examples of how to move forward in eliminating this devastating disease.

Blinding trachoma: a disease of poverty

Trachoma accounts for 15% of blindness worldwide, affecting the world's poorest communities. How can the disease be controlled?