The limits of medical interventions for the elimination of preventable blindness

Effectiveness and safety of azithromycin 1.5% eye drops for mass treatment of active trachoma in a highly endemic district in Cameroon

Objective

To evaluate the effectiveness and safety of azithromycin 1.5% eye drops under field conditions to reduce active trachoma in a highly endemic district in Cameroon. This is a follow-up of an initial report published in 2010.

Methods and analysis

Three annual campaigns were performed in 2008, 2009 and 2010 to treat the population (~1 20 000 individuals) of the Kolofata Health District with topical azithromycin 1.5% (one drop in each eye, morning and evening for three consecutive days). The effectiveness of this intervention against active trachoma was assessed in children aged 1–9 years in cross-sectional studies prior to each mass treatment using a systematic sampling procedure (in 2008, 2009 and 2010) and then 1 year (2011) and 3 years (2013) after the last intervention among the villages with previously high active trachoma prevalence or never tested.

Results

The prevalence of trachomatous inflammation—follicular (TF) dropped from 24.0% (95% CI 20.7 to 27.5) before treatment to 2.8% (95% CI 2.2 to 3.7) 1 year after completion of the 3 year campaign. Trachomatous inflammation—intense was present in only 4 (0.2%) children 1 year after the third round of treatment. Three years after the last campaign, the surveillance survey among the most prevalent villages and villages never tested before showed a prevalence of 5.2% (95% CI 3.6 to 7.2) of active trachoma. Tolerance was excellent, with no report of treatment interruption, serious ocular or systemic adverse events.

Conclusion

Annual mass treatment with azithromycin eye drops was shown to be effective in reducing TF to a level ≤5% one year after a 3-round annual mass treatment in an endemic region at the district level.

Household Survey of Trachoma among Children Living in Pernambuco, Brazil

This study analyzed the association between individual and household factors and the incidence of trachoma among a population aged between 1 and 9 years in the state of Pernambuco. This was a population-based household study conducted using a population-based sample of residents from 96 census sectors of the 1778 sectors considered to be at social risk in the state. The estimated odds ratio of the univariate analysis presented a confidence interval of 95%. Weights and clusters were adjusted through the Generalized Linear and Latent Mixed Model (GLLAM) method. Trachoma cases were the dependent variable in the multivariate analysis. The independent variables were selected through the stepwise forward method, with an input criterion of 20% (p < 0.20) and an output criterion of 10% (p < 0.10). The prevalence was 6.65%. Trachoma was associated with a female sex, age of 5–9 years, either the absence of use or infrequent use of soap to wash the hands and face, the presence of nasal secretion, a lack of piped water from a public supply system, a greater number of rooms used for sleeping, a greater number of people living in the same household, and a family income of up to one minimum monthly wage. The prevalence of follicular trachoma in Pernambuco was higher than what is recommended by the World Health Organization (WHO).

Perceptions and practices of community members relating to trachoma in Africa: a qualitative systematic review protocol

OBJECTIVE

The objective of this systematic review is to synthesize and present the best available evidence on community perceptions and practices relating to trachoma in Africa.

INTRODUCTION

Globally, trachoma is the leading cause of blindness and is responsible for about 1.4% of all cases of blindness. The African continent is the worst affected, with about 1.9 million cases of trichiasis (61%). While interventions are currently being implemented to combat the disease in Africa, very little is known by decision makers about community perceptions and practices relating to trachoma, which may hinder successful implementation.

INCLUSION CRITERIA

Studies with participants, regardless of their health status, gender, religion and ethnicity, aged 14 and over conducted in any African country, will be considered. Studies on Africans, conducted out of the continent and those involving healthcare professionals, will not be included in this review.

METHODS

Qualitative studies, published in English from 1996 onwards. will be considered. Databases to be searched will include, but not be limited to: PubMed, CINAHL, Embase and PsycINFO. Study selection, critical appraisal and data extraction will be conducted by two independent reviewers, using the appropriate JBI methodology and any disagreement will be resolved by discussion or with a third reviewer. Qualitative findings will be synthesized using the appropriate JBI methodology, following the meta-aggregation approach. Where textual pooling is not possible, the findings will be presented in narrative form. The ConQual approach will be used to grade synthesized findings, and these will be presented in a Summary of Findings.

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.

Social Sciences for the Prevention of Blindness

Organizations working for the elimination of Chlamydia-triggered blindness (trachoma) follow the WHO SAFE strategy (surgery for trichiasis, antibiotics, face washing and environmental changes) with the aim to achieve a minimum of 80% of children with clean faces in endemic communities, mass treatment covering the whole district with trachoma rates of 10% or more and surveillance plans. Trachoma recurrence that is common after implementing the SAFE strategy 3, 5 or even 7 times evidence that the cognitive processes requiring assimilation and integration of knowledge did not register with parents, caretakers and children. Moreover, repeated awareness campaigns to improve hygiene did not systematically produce irreversible changes of behavior in neglected populations. In view of this evidence, the rational behind mass drug administration as the mainstay of preventable blindness elimination demands a wider scope than simple mathematical models. The reluctance to see disappointing outcomes that leads to repeated interventions may suggest from a sociologic point of view that the strategies are products of those evaluating the activities of those who fund them and vice versa. A similar articulation emerges for reciprocal interactions between researchers and those judging the pertinence and quality of their work. So far, the lack of autocritic elimination strategy approaches may expose inbred circles that did not properly grasp the fact that antibiotics, trichiasis surgery and education limited to improvement of hygiene are inefficient if not associated with long-term basic educational actions in schools.

Rethinking eye health systems to achieve universal coverage: the role of research

Achieving universal coverage in eye care remains a tremendous challenge as 226 million people in the world remain visually impaired, the majority from avoidable causes. The impact of eye care interventions has been constrained by the limited capacities of health systems in low-income and middle-income countries to deliver effective eye care services. Services for eye health are still not adequately integrated into the health systems of low-income and middle-income countries. We contend that radical rethinking and deeper development of eye health systems are necessary to achieve VISION 2020 goals. Responding to the challenges of chronic eye diseases will require systems thinking, analysis and action, based on evidence from health systems research.