Prevalence of trachomatous trichiasis in Australia: the National Eye Health Survey.

IMPORTANCE: Australia is the only developed country to still have pockets of endemic trachoma. The research provides up-to-date, population-based prevalence data of later complications of trachoma amongst a national sample of Indigenous adults. BACKGROUND: To report the prevalence of trachomatous trichiasis (TT) in Indigenous Australians aged 40 years and older. DESIGN: Population-based cross-sectional study. PARTICIPANTS: A total of 1738 (41% male) Indigenous Australians aged 40 years or older, living amongst 30 randomly selected Australian sites, stratified by remoteness. METHODS: Anterior segment examination was performed and trachoma grading for the presence of TT and corneal opacification (CO) was conducted using the WHO (WHO) simplified grading system. MAIN OUTCOME MEASURES: Prevalence of TT. RESULTS: A total of three (0.17%) participants had TT, and there were no confirmed cases of trachomatous CO in the NEHS. All three participants with TT were female and aged 40 years or older. Although they had likely spent their childhoods in more remote areas, two of the three confirmed cases resided in an urban and outer regional area at the time of their examinations. CONCLUSIONS AND RELEVANCE: Our data are in line with ongoing national trachoma surveillance reports that suggest the prevalence of late sequences of trachoma appear to be decreasing in Australia.

National trachoma surveillance annual report, 2012.

Australia remains the only developed country to have endemic levels of trachoma (a prevalence of 5% or greater among children) in some regions. Endemic trachoma in Australia is found predominantly in remote and very remote Aboriginal communities. The Australian Government funds a National Trachoma Surveillance and Reporting Unit to collate, analyse and report trachoma prevalence data and document trachoma control strategies in Australia through an annual surveillance report. This report presents data collected in 2012. Data are collected from Aboriginal and Torres Strait communities designated as at-risk for endemic trachoma in the Northern Territory, Queensland, South Australia and Western Australia. The World Health Organization grading criteria were used to diagnose cases of trachoma in Aboriginal children with jurisdictions focusing screening activities on the 5-9 years age group; however, some children in the 1-4 and 10-14 years age groups were also screened. The prevalence of trachoma within a community was used to guide treatment strategies as a public health response. Aboriginal adults aged 40 years or older were screened for trichiasis. Community screening coverage of the designated at-risk communities was 96%. Screening coverage of the estimated population of children aged 5-9 years and adults aged 40 years or older in at-risk communities was 71% and 31%, respectively. Trachoma prevalence among children aged 5-9 years who were screened was 4%. Of communities screened, 63% were found to have no cases of active trachoma and 25% were found to have endemic levels of trachoma. Treatment was required in 87 at-risk communities screened. Treatment coverage of active cases and their contacts varied from 79%-97% between jurisdictions. Trichiasis prevalence was 2% within the screened communities.

The "Oriental" problem: trachoma and Asian immigrants in the United States, 1897-1910.

This essay examines the period between 1897 and 1910, when trachoma, a contagious eye disease, became an "Oriental" problem that justified exclusionary immigration policy against Asians entering the United States. It also investigates the ways in which the public fear and alleged threat of the eye disease destabilized and undermined the rights of Asian immigrants. Many scholars have explored the link between trachoma and southern and eastern European newcomers, in particular Jews, but they have not paid much attention to Chinese or Japanese immigrants, for whose exclusion trachoma played a significant role. This is primarily because the number of Asian immigrants was much smaller than that of their European counterparts and because the Chinese Exclusion Acts, which had already been in place, functioned as a stronger and more lasting deterrent to Asian immigration than exclusion or deportation through medical inspection. Moreover, into the 1910s, medical and scientific innovations for detecting parasitic diseases (e.g. hookworm) helped American authorities exclude Asians in larger numbers. Still, the analysis of the discourses surrounding trachoma and immigration from Asia, though short-lived, demonstrates the role of medical inspection in controlling and regulating Asian immigrants, in particular Chinese and Japanese, into the United States and in constructing their legal and political rights. In 1906, the fear of trachoma justified an order to segregate Japanese students from white children in San Francisco even at the cost of compromising their rights as citizens. Along with fierce criticisms against immigration officials by the American public, the 1910 investigation of the San Francisco Immigration Office problematized the admission of trachoma-afflicted Asian immigrants. Those critical of the Immigration Office and its implementation of American immigration policy called for exclusionary measures to limit the privileges of exempt classes and domiciled aliens and hinder the exertion of their rights to leave and reenter their adopted country. The two examples show that trachoma was a convenient excuse to condemn inefficient immigration policy and regulate allegedly diseased Asian bodies. In 1910, the federal government made a decision to relegate to steamship companies full responsibility for medical inspection at Asian ports. Since they had to pay a fine for every immigrant excluded at American borders for medical reasons, including trachoma, steamship companies carried out more rigorous examinations. With medical advancements and growing interest in parasitic diseases, trachoma soon lost its appeal to immigration authorities. However, the association of immigration, race, and disease has continued to provide a rationale for immigration control beyond American borders.

Incidence of visual impairment due to cataract, diabetic retinopathy and trachoma in indigenous Australians within central Australia: the Central Australian Ocular Health Study.

BACKGROUND: To estimate the incidence and causes of visual impairment for the purposes of service provision among the indigenous Australian population within central Australia from its most common causes, namely cataract, diabetic retinopathy and trachoma. DESIGN: Clinic-based cohort study. PARTICIPANTS: One thousand eight hundred eighty four individuals aged ≥20 years living in one of 30 remote communities within the statistical local area of 'Central Australia'. METHODS: From those initially recruited, 608 (32%) participants were reviewed again between 6 months and 3 years (median 2 years). Patients underwent Snellen visual acuity testing and subjective refraction. Following this, an assessment of their anterior and posterior segments was made. Baseline results were compared with those who were reviewed. MAIN OUTCOME MEASURES: The annual incidence rates and causes of visual impairment (vision worse than Snellen visual acuity 6/12 in at least one eye). RESULTS: The incidence of visual impairment in at least one eye was 6.6%, 1.2% and 0.7% per year for cataract, diabetic retinopathy and trachoma, respectively (7.9%, 1.5% and 0.7% per year for those aged ≥40 years). Advancing age was the main risk factor common to all three. CONCLUSION: It is important to be mindful not only of the prevalence of disease in a community but also of the rate at which new cases are occurring when allocating resources to address the ocular health needs of this region. Compared with historical data, diabetic retinopathy is emerging as a new and increasing threat to vision in this population.

Epilation for trachomatous trichiasis and the risk of corneal opacification.

PURPOSE: Eight million people have trachomatous trichiasis (TT). The World Health Organization (WHO) recommends entropion surgery for TT regardless of severity. However, epilation is widely practiced for treating minor TT (1-5 lashes touching the globe). We report the frequency and effectiveness of patient-initiated epilation and its relationship to corneal opacity. DESIGN: Cross-sectional baseline data of individuals recruited to 2 randomized, clinical trials. PARTICIPANTS: We included 2556 individuals (4310 eyes) with previously unoperated TT in ≥ 1 eye. METHODS: A single ophthalmologist examined all participants for signs of trachoma using WHO grading systems with additional assessment of entropion grading, location and number of trichiatic lashes, and evidence of epilation. A questionnaire enquired about epilation practices. MAIN OUTCOME MEASURES: The association between epilation and degree of corneal opacity. Epilation practices of TT patients. RESULTS: Central corneal scarring was present in 1436 (33%) eyes. Entropion was absent/mild in 2328 (54%) eyes, moderate in 1259 (29.2%), and severe in 723 (16.8%). The median number of lashes touching the eye was 2 (interquartile range, 1-5; range, 0-133). There was clinical evidence of epilation in 3018 (70%) eyes, of which 738 (24%) were successfully epilated (no lashes touching globe). Epilation was performed frequently (at least monthly in 3311 [76.8%] eyes), by someone other than the patient (92.8%), and using locally made forceps (88.9%). Controlling for age and degree of entropion, successful epilation was associated with less corneal opacity (odds ratio [OR], 0.61; 95% confidence interval [CI]. 0.43-0.88; P = 0.007). The association was only significant in patients with severe entropion (OR, 0.07; 95% CI, 0.02-0.25; P<0.005). CONCLUSIONS: We found an association between successful epilation and less central corneal opacity. This indicates the importance of preventing eyelashes from touching the cornea, particularly in individuals with severe entropion. This is a cross-sectional study; therefore, a causative relationship cannot be concluded. However, the results suggest that among patients who decline or are unable to access surgery, and perhaps in minor TT where the management remains controversial, the provision of high-quality forceps and epilation training may be beneficial. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Prevalence of trachoma in a single community, 1975-2007.

BACKGROUND: To determine the change in the prevalence in active trachoma in children in a remote Aboriginal community over a 32-year period. DESIGN: Data used from two cross-sectional studies repeated in the same community 32 years apart. PARTICIPANTS OR SAMPLES: Children aged 5-13 years living in the community. METHODS: Thirty-five mm photographs of the everted upper lid taken in 1975 and digital photographs taken in 2007 were graded using a fine trachoma-grading scheme. MAIN OUTCOME MEASURE: The age-specific prevalence and severity of trachoma was compared at the two time points. RESULTS: Images were available from 82 children in 1975 and from 92 children in 2007. The overall prevalence of active trachoma (trachomatous inflammation follicular and or trachomatous inflammation intense) was 59% in 1975 and in 2007 was significantly lower at 23% (P<0.001). The overall severity grades of active trachoma had also decreased significantly for each sign from 1975 to 2007 (all P values from the rank-sum test were less than 0.001). However, in 2007, there were still some children with severe active trachoma and severe scarring still occurred. CONCLUSION: Although the prevalence and severity of active trachoma in children have decreased significantly over the last 30 years in this community, trachoma still remains a significant public health problem. One third of the children have active trachoma, a figure in excess of the threshold set as a public health problem by the World Health Organization.

Trachoma, cataracts and uncorrected refractive error are still important contributors to visual morbidity in two remote indigenous communities of the Northern Territory, Australia.

PURPOSE: To assess the contribution of trachoma, cataract and refractive error to visual morbidity among Indigenous adults living in two remote communities of the Northern Territory. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional survey of all adults aged 40 and over within a desert and coastal community. MAIN OUTCOME MEASURES: Visual acuity, clinical signs of trachoma using the simplified WHO grading system and assessment of cataract through a non-dilated pupil. RESULTS: Two hundred and sixty individuals over the age of 40 years participated in the study. The prevalence of visual impairment (<6/12) was 17%. The prevalence of blindness (<3/60) was 2%, 40-fold higher than seen in an urban Australian population when adjusted for age. In total, 78% of adults who grew up in a desert community had trachomatous scarring compared with 26% of those who grew up in a coastal community (P < or = 0.001). In the desert community the prevalence of trachomatous trichiasis was 10% and corneal opacity was 6%. No trachomatous trichiasis or corneal opacity was seen in the coastal community. CONCLUSIONS: Trachoma, cataract and uncorrected refractive error remain significant contributors to visual morbidity in at least two remote indigenous communities. A wider survey is required to determine if these findings represent a more widespread pattern and existing eye care services may need to be re-assessed to determine the cause of this unmet need.

Trachoma in Indigenous Settlements in Brazil, 2000-2008.

PURPOSE: Trachoma, caused by the bacterium Chlamydia trachomatis, is a chronic, recurrent inflammatory disease that affects the cornea and conjunctiva. Trachoma is the leading infectious cause of avoidable blindness worldwide. Its prevalence is higher among individuals of low socioeconomic status, and trachoma is common in indigenous communities. The present study presents aspects of the epidemiological profile of trachoma in indigenous communities in Brazil. METHODS: We analyzed data from two databases collected during trachoma screening activities among the population of indigenous settlements in Brazil between 2000 and 2008. Trachoma cases were detected by ocular examination in accordance with the World Health Organization simplified trachoma grading system. RESULTS: According to the surveillance database, a total of 9582 individuals in six different states were examined. Among children aged 1-9 years, the prevalence of follicular trachomatous inflammation (TF) was 35.2%. In individuals aged ≥15 years, the prevalence of trachomatous trichiasis (TT) was 1.2% in individuals and the sex-specific prevalence was 0.8% in males and 1.6% in females (p = 0.02). In a survey of two states, 2301 indigenous schoolchildren were examined. In the age bracket 5-9 years, the prevalence of TF was 4.9 (95% confidence interval 3.8-6.0%). CONCLUSION: In Brazil, trachoma appears to be a serious public health problem in indigenous settlements, which should therefore be given priority in programs aimed at the elimination of trachoma in the country.

Trachoma in remote Indigenous Australia: a review and public health perspective.

OBJECTIVES: Trachoma remains a major health concern in many remote Indigenous Australian communities, despite behaviour-modifying and biomedical strategies. This review aims to examine the social epidemiology of trachoma in remote Indigenous communities and identify practical, sustainable strategies to alter the social determinants of the disease. METHODS: A systematic search and critical review explored the proximal, intermediate and distal determinants of trachoma. The impact of swimming pools in remote Indigenous communities on trachoma and other infectious diseases was further examined. RESULTS: Having a clean face was found to be protective for trachoma, but face-washing education programs have produced no significant benefits. Sanitation infrastructure in a community was the key determinant of facial cleanliness. Installation of swimming pools in remote Indigenous communities has been demonstrated to reduce the prevalence of several common childhood infections. However, minimal research has explored the impact of pools on trachoma rates. CONCLUSIONS: The locally supported construction of pools in remote Indigenous communities may contribute to a decline in trachoma. A prospective, controlled trial is needed to test this hypothesis in endemic communities. IMPLICATIONS: If validated by a well-designed study, pool construction may provide a much sought-after practical government strategy to combat trachoma in remote Indigenous communities.

Chlamydia trachomatis from Australian Aboriginal people with trachoma are polyphyletic composed of multiple distinctive lineages.

Chlamydia trachomatis causes sexually transmitted infections and the blinding disease trachoma. Current data on C. trachomatis phylogeny show that there is only a single trachoma-causing clade, which is distinct from the lineages causing urogenital tract (UGT) and lymphogranuloma venerum diseases. Here we report the whole-genome sequences of ocular C. trachomatis isolates obtained from young children with clinical signs of trachoma in a trachoma endemic region of northern Australia. The isolates form two lineages that fall outside the classical trachoma lineage, instead being placed within UGT clades of the C. trachomatis phylogenetic tree. The Australian trachoma isolates appear to be recombinants with UGT C. trachomatis genome backbones, in which loci that encode immunodominant surface proteins (ompA and pmpEFGH) have been replaced by those characteristic of classical ocular isolates. This suggests that ocular tropism and association with trachoma are functionally associated with some sequence variants of ompA and pmpEFGH.

Trachoma and ethnic diversity in the Upper Rio Negro Basin of Amazonas State, Brazil.

A trachoma survey was carried out among three culturally different populations of the Upper Rio Negro Basin in the Brazilian rain forest of Amazonas State. The results indicate that trachoma is prevalent in the region, reaching hyperendemic levels (between 50.9% and 56.4%) in all communities studied. However, the severity of the disease appears to be related to the ethnic origin of the tribes, following the rank of social and cultural values that regulate the complex interactions between the Indian groups of the region.

Assessment of trachoma prevalence in a mobile population in Central Australia.

Trachoma is reported to be hyperendemic in Australia. This study was conducted in a desert area of Central Australia to implement and evaluate the WHO SAFE strategy to control trachoma. The aim of the study was to obtain baseline trachoma prevalence data and to determine whether a single annual visit is adequate for a treatment program targeting households with active cases in a highly mobile population. All registered residents of two Aboriginal communities were eligible for examination. Four visits over the course of 13 months were made to the communities for ocular examinations of residents present at the time of the visit. Examination, diagnosis, and grading of trachoma followed WHO guidelines. The overall examination rate was 75%, refusal rate was <1%, but approximately 50% of community residents were absent during the examination period. Prevalence varied on each visit, but the overall prevalence of active trachoma was 49% over the 13-month period. Children less than 10 years of age had the highest prevalence of active trachoma (79%), over the course of the 13 months, yet the prevalence at any one visit was approximately 60%. Trachomatous scarring was present in 23% of the population. These results suggest that many cases of active trachoma may be missed if a prevalence survey is conducted at only one point in time. Multiple examinations should be conducted to adequately establish prevalence in the population. Antibiotic treatment and health promotion campaigns need to be developed in consideration of local community dynamics.

Trachoma among the Yanomami Indians.

The Yanomami are one of the last primitive groups of Indians living in Brazil. They have almost no contact with other cultures. The epidemiology of eye disease among Yanomami is virtually unknown. For the first time, a trachoma survey was conducted among Yanomami Indians in the State of Amazonas near the Venezuelan border of the Brazilian rain forest. Ophthalmic examination was carried out on a total of 613 individuals (338 males and 275 females) from eight Yanomami villages along the Maraui River located in the upper Rio Negro Basin. Age was classified into three categories (children, adults, and elderly) and trachoma was classified into five grades: follicular, inflammatory intense, cicatricial, trichiasis, and corneal opacity. Trachoma was endemic in all villages visited. Overall, 30.3% of the subjects had trachoma. Females were significantly more affected (37.4%) than males (23.9%). The inflammatory trachoma rate reached 24.9% in children and the cicatricial form increased with age, reaching 13.9% among adults and 35.21% among the elderly. Trichiasis or corneal opacities were not detected and treatment of the entire population was initiated with 1 g azithromycin. The detection of endemic trachoma among the Yanomami is relevant for the understanding of the epidemiology of this disease in the Brazilian rain forest and underscores the necessity for a program of trachoma control in this region.

A pilot study into the prevalence of ophthalmic disease in the Indian population of Southall.

A pilot study was carried out to determine the prevalence of ophthalmic disease in the Indian community of Southall and to ascertain the best methods applicable for a larger formal study. Three sites were chosen for the study, a Sikh gurdwara, a mosque and a Hindu temple. The subjects were volunteers aged 30 years and over who had visited the appropriate place of worship at least twice in the previous month. A total of 184 subjects were examined. The prevalence of blindness was 2.7% by the World Health Organization (WHO) criteria, while 9.8% had uniocular blindness. The prevalence of glaucoma and ocular hypertension was 2.7% and 7%, respectively. Of the 184 subjects examined, 58% had cataract and 3.8% had age-related maculopathy. The prevalence of visually disabling trachomatous eye disease was 9.7%. The prevalence of diabetes mellitus was 17.9%, and that of hypertension 22.8%. This small study suggests that people with origins from the Indian subcontinent have a higher prevalence of ophthalmic disease than the Caucasian population.

[Community health and social action in the epidemiologic control of infantile trachoma, Spain (1932-1939)]. / Salud comunitaria y acción social en el control epidemiologíco del tracoma infantil, España (1932-1939).

Within the context of the endemic trachoma that affected different regions of Spain until the 1960s, this paper analyses the epidemiological determinants of child trachoma and its treatment, based on a preventive care model which incorporated the concept of community health that took shape during the interwar period. Early detection of cases, together with preventive measures, education, therapy and inspections, such as those carried out by visiting nurses, all helped to control the disease. Our results reaffirm the validity of the horizontal intervention strategies used for improving the sanitary conditions and environmental factors responsible for this prevalence of trachoma.