OUP accepted manuscript

Optimizing Trichiasis Case Finding to Attain the Elimination of Trachoma as a Public Health Problem

BACKGROUND

As national trachoma programmes increase efforts to reduce the burden of trachomatous trichiasis (TT), TT case finding and referral are critical public health programme components. Our research aimed to explore the most effective and efficient approaches to finding, referring, and managing TT cases.

METHODS

This was a prospective descriptive study, utilizing both routine programme data and primary data collection. This study compared four different approaches to finding TT cases across three different local government areas (LGAs) in Kano State, Nigeria. Each of the study LGAs was divided into four sub-units to accommodate the four different approaches.

RESULTS

The number of outreach attendees was 4795 across the four case finding approaches, and this varied hugely, with the smallest number and proportion (403, 0.26%) in settings only employing house-to-house case finding and the largest number and proportion (1901, 0.99%) when town criers were used. That said, the proportion of TT cases among people presenting at outreach was highest (32.5%) when house-to-house case finding was used and lowest (10.3%) when town criers were used. More female TT patients were found (53-70%) and had surgery (79-85%) compared to male cases, across all approaches. The average project expenditure for finding one TT case was similar for approaches that included house-to-house case finding (USD 5.4-6.3), while it was 3.5 times higher (USD 21.5 per TT case found) when town criers were used.

DISCUSSION

This study found that the house-to-house TT case finding approaches were the most efficient method with the highest yield of TT cases. Including other eye condition and/or vision testing yielded similar results but required more personnel and cost.

Progress Towards Elimination of Trachoma in Kenya 2017-2020

PURPOSE

Trachoma is endemic in Kenya. Since baseline trachoma surveys in 2004, a concerted programme has been undertaken to reduce the prevalence of disease. Here, we report on trachoma prevalence surveys carried out between 2017 and 2020 after interventions were implemented in some areas for trachoma elimination purposes.

METHODS

A total of 48 cross-sectional population-based trachoma prevalence surveys were conducted in 39 evaluation units (EUs; covering 45 subcounties) of Kenya between 2017 and 2020. Thirty EUs were surveyed once and nine EUs were surveyed twice over this period. Individuals ≥ 1 year old were assessed for trachomatous inflammation-follicular (TF), trachomatous inflammation-intense (TI) and trichiasis. Data were collected on household access to water, sanitation and hygiene (WASH).

RESULTS

A total of 147,573 people were examined. At the end of 2020, in the 39 EUs surveyed, the prevalence of TF in 1-9-year-olds was ≥5% in 11 EUs and the prevalence of trichiasis unknown to the health system in individuals aged ≥15 years was ≥0.2% in 25 EUs. A small minority of households (median <50% for all indicators) had access to improved WASH facilities.

CONCLUSION

Kenya has made excellent progress towards elimination of trachoma as a public health problem. However, there is more work to do. Between one and three rounds of antibiotic mass drug administration are required in 11 EUs. Sustained investment in surgical provision, continued TT case-finding, promotion of facial cleanliness and environmental improvement are required throughout the surveyed area.

Effectiveness of Trachomatous Trichiasis Case-identification Approaches in Ethiopia

BACKGROUND

Trachoma control programs use multiple approaches to identify individuals with trachomatous trichiasis (TT). Evidence is limited regarding which approaches are most effective and cost-efficient.

METHODS

We evaluated the effectiveness of two TT case-identification approaches in Ethiopia: community mobilization to encourage self-referral for centralized screening and house-to-house screenings conducted by case finders. We compared the number of true cases found per 1000 population and costs associated with case identification under each approach, stratified by villages that received one or multiple screening visits.

RESULTS

We conducted screenings in 396 villages. In villages receiving one house-to-house visit, case finders identified 14,229 suspected cases, of whom 10,513 (73.9%) presented for TT confirmation. A median of 17.2% (interquartile range [IQR]: 9.1%-27.8%) of those presenting truly had TT (positive predictive value). In single-visit villages, the community mobilization approach yielded higher rates of confirmed cases than the house-to-house approach (1.5 [IQR: 1.1, 2.6] vs. 1.1 [IQR: 0.5, 1.9] cases per 1000 population), and the median cost of identifying a TT case was less ($5.59 vs. $31.18) using community mobilization than house-to-house. In multiple-visit villages, additional screening visits increased the median rate of confirmed cases to 2.5 per 1000 population in community mobilization villages, but the rate remained unchanged in house-to-house villages.

CONCLUSIONS

Community mobilization-based TT case finding had a higher yield than house-to-house, at a substantially lower cost. Future research should examine whether additional tools to aid case finders in their diagnosis increases case-finding efficiency and accuracy and whether TT prevalence and surgical program duration impact case-finding success.

Understanding the Role of Gender in Trichiasis Case Finding in Tanzania

PURPOSE

Despite the importance of trachomatous trichiasis (TT) case-finding activities in national trachoma elimination campaigns, the scientific literature on the determinants of good outcomes - finding and managing all TT cases - is still sparse. In Tanzania, we studied differences in case finding activities and outcomes between male and female case finders.

METHODS

This case study was conducted in two districts in Tanzania in 2021-2022. Quantitative data were extracted from case finder forms and outreach registers, and qualitative data were collected through direct observation, interviews, and focus group discussions.

RESULTS

Across both districts, more males were trained as case finders (68%). Productivity differences were minor, not statistically significant, between male and female case finders regarding the number of households visited and the number of adults examined. Whether identified by a male or female case finder, similar proportions of men and women suspected to have TT were subsequently managed. There is evidence that suggests that female case finders were more active in supporting suspected and confirmed TT cases to access follow-up services.

CONCLUSION

The findings do not suggest that gender balance in the recruitment of TT case finders would have led to better TT campaign outcomes in the study districts. Programmes may benefit from integrating gender considerations in the design and implementation of case finding activities - e.g. in monitoring gender differences among case finders and the relationship with key outcomes. This study also highlights how women with TT face greater barriers to care.