Risk factors for the progression of trachomatous scarring in a cohort of women in a trachoma low endemic district in Tanzania

Background Trachoma, a chronic conjunctivitis caused by Chlamydia trachomatis, is the leading infectious cause of blindness worldwide. Trachoma has been targeted for elimination as a public health problem which includes reducing trachomatous inflammation—follicular prevalence in children and reducing trachomatous trichiasis prevalence in adults. The rate of development of trachomatous trichiasis, the potentially blinding late-stage trachoma sequelae, depends on the rate of trachomatous scarring development and progression. Few studies to date have evaluated the progression of trachomatous scarring in communities that have recently transitioned to a low trachomatous inflammation—follicular prevalence. Methodology/Principal findings Women aged 15 and older were randomly selected from households in 48 communities within Kongwa district, Tanzania and followed over 3.5 years for this longitudinal study. Trachomatous inflammation—follicular prevalence was 5% at baseline and at follow-up in children aged 1–9 in Kongwa, Tanzania. 1018 women aged 15 and older had trachomatous scarring at baseline and were at risk for trachomatous scarring progression; 691 (68%) completed follow-up assessments. Photographs of the upper tarsal conjunctiva were obtained at baseline and follow-up and graded for trachomatous scarring using a previously published four-step severity scale. The overall cumulative 3.5-year progression rate of scarring was 35.3% (95% CI 31.6–39.1). The odds of TS progression increased with an increase in age in women younger than 50, (OR 1.03, 95% CI 1.01–1.05, p = 0.005) as well as an increase in the household poverty index (OR 1.29, 95% CI 1.13–1.48, p = 0.0002). Conclusions/Significance The 3.5-year progression of scarring among women in Kongwa, a formerly hyperendemic now turned hypoendemic district in central Tanzania, was high despite a low active trachoma prevalence. This suggests that the drivers of scarring progression are likely not related to on-going trachoma transmission in this district.

Exploring barriers for trachomatous trichiasis surgery implementation in gamo zone, Southern Ethiopia

Background Trachomatous trichiasis is the leading infectious cause of blindness worldwide. The World Health Organization recommends eyelid surgery to reduce the risk of visual impairment from trichiasis. Unfortunately, the number of cases operated has grown less than expected. An understanding of barriers is fundamental for instituting measures to increase surgical uptake. Therefore, the aim of this study was to explore barriers of TT surgery implementation. Methods A qualitative study design was employed in December 2019. Purposive sampling technique was used to select three districts from Gamo zone, Southern Ethiopia. We conducted 9 FGDs and 12 in-depth interviews. Data was collected by audio tape recorder in Amharic and Gamogna languages and then transcribed to English language. The recorded interviews and focus group discussions were transcribed to verbatim (written text) and thematic analysis was done manually and reported accordingly. Findings we explored a number of barriers that hindered implementation of trichiasis surgery. The recurrence of trichiasis after surgery was the main challenges faced by operated individuals. The other barriers reported are negative perception towards trichiasis surgery, lack of logistic and supplies, transportation access problem for remote communities, inadequate trained health professional, less commitment from higher officials, lack of interest of integrated eye care workers due to incentive issues, believes of patients waiting supernatural power for healing service and carelessness of patients to undertake operation. Conclusion and recommendation Post-surgical trichiasis, lack of commitment from government officials and negative perception of patients towards the disease were considered as the reported barriers for implementation of trachomatous trichiasis. Closely supervising the integrated eye care workers would be the first task for district health offices to increase the uptake and improve the quality of service. Logistics and supplies should be made available and adequate to address all affected people in the community.

Prevalence and Determinants of Trachomatous Trichiasis towards Elimination of Trachoma in Ethiopia: A Systematic Review and Meta- Analysis

Background: Trachomatous Trichiasis is a preventable and treatable late stage of trachoma infection, mainly exacerbating the condition of poor and marginalized people. Given the hurtful nature of the infection, many countries, including Ethiopia, lack coherent data on the status of the problem toward its targeted time of elimination. Hence, this systematic review and meta-analysis aimed to provide a comprehensive overview of the prevalence and determinants of trachomatous trichiasis towards the elimination of trachoma in Ethiopia.Methods: Based on the predefined criteria, electronic database searches on the peer-reviewed journal papers of an English version were reviewed on the prevalence and determinants of trachomatous trichiasis among the adult population in Ethiopia from January 2015 to December 2020. After reviewing the quality of the individual sources of evidence by three reviewers, the data items were extracted using a locally devised charting form. Data were synthesized qualitatively and quantitatively in terms of publication year, design, study participants, and outcome of interest. Finally, quantitative results were pooled, explored for sources of variation, tested for a potential source of influence of prevalence estimates and publication bias in the statistical meta-analysis using STATA version-16 software.Result: After the exclusion of 121 duplicates, 108 extraneous titles & abstracts, and removal of three articles for the reasons detected on full-text screening, ten eligible studies were included for analysis. All the included studies were cross-sectional studies that took prevalence as the main outcome of interest. Accordingly, the overall pooled prevalence of Trachomatous trichiasis was 1.80 % (95%CI=1.15, 2.44) while an individual prevalence estimate of the studies ranged from 0.5% (95%CI= 0.42, 0.60) to 3.9 % (95%CI=3.82, 3.98). On subgroup analysis, the highest [3.76% (95% CI = 3.20, 4.41)] and the lowest [0.5% (95%CI= 0.42, 0.60)] prevalence were respectively reported in Gambella and Somalia. The trend of the prevalence has demonstrated unstable pattern, while there were no published studies on the determinants of trachoma trichiasis among adult over the specified period of the review.Conclusion: The prevalence of TT was significantly higher than the elimination threshold in all regions of Ethiopia, needing further implementation to facilitate roads toward the elimination.Trail registration: CRD42021260802

Patient perceived barriers to surgical follow-up: Study of 6-month post-operative trichiasis surgery follow-up in Tanzania

Background Post-surgical follow-up is a challenge in low- and middle-income countries. Understanding barriers to trachomatous trichiasis (TT) surgical follow-up can inform program improvements. In this study, patient perceived barriers and enabling factors to follow-up after TT surgery are identified. Methods A longitudinal study was carried out in a community-based cohort of persons who received TT surgery in Bahi district, Tanzania. Questionnaires were administered before TT surgery and again after the scheduled 6-month follow-up. Those who did not return were examined at their homes. Results At baseline, 852 participants were enrolled. Of these, 633 (74%) returned at 6 months and 128 (15%) did not and were interviewed at home. Prior to surgery, attenders were more likely to report familiarity with a community health worker (CHW) (22% vs. 14%; p = 0.01) and less likely to state that time constraints are a potential reason for failure to follow-up (66% vs. 74%; p = .04). At follow-up, non-attenders were more likely to endorse barriers pertaining to knowledge about the need for follow-up, lack of transportation, and satisfaction with surgery. There was no difference in post-operative TT between attenders and non-attenders (23% vs. 18% respectively; p = 0.25). Conclusions The outcome of surgery was not a barrier to follow-up. However, better integration of CHWs into their communities and work at coordinating post-surgical care may improve follow-up rates. Moreover, provision of transportation and implementation of effective reminder systems may address patient-perceived barriers to improve follow-up.

Evaluation and implementation of a mannequin-based surgical simulator for margin-involving eyelid laceration repair – a pilot study

Background Repair of margin-involving eyelid lacerations is a challenge for beginning ophthalmology residents, yet no commercially-available simulation models exist for learning this skill. The objective of the study was to modify a mannequin-based surgical simulator originally developed for trachomatous trichiasis surgery training to teach margin-involving eyelid laceration repair and to evaluate its success within a residency wet-lab environment. Methods We modified a previously developed mannequin-based training system for trachomatous trichiasis surgery into a simulator for margin-involving eyelid laceration repair. Six ophthalmology residents from a tertiary care academic institution performed at least one simulated margin-involving eyelid laceration repair using the surgical simulator between September 2019 and March 2020. Each session was video recorded. Two oculoplastic surgeons reviewed the videos in a blinded fashion to assess surgical proficiency using a standardized grading system. Participants were surveyed on their comfort level with eyelid laceration repair pre- and post-completion of simulation. They were also queried on their perceived usefulness of the surgical simulator compared to past methods and experiences. Results Six residents completed 11 simulation surgeries. For three residents who completed more than one session, a slight increase in their skills assessment score and a decrease in operative time over two to three simulation sessions were found. Self-reported comfort level with margin-involving eyelid laceration repairs was significantly higher post-simulation compared to pre-simulation (p = 0.02). Residents ranked the usefulness of our surgical simulator higher than past methods such as fruit peels, surgical skill boards, gloves, and pig feet (p = 0.03) but lower than operating room experience (p = 0.02). Residents perceived the surgical simulator to be as useful as cadaver head and emergency department/consult experience. Conclusions We developed a surgical simulator for teaching eyelid laceration repair and showed its utility in developing trainees’ surgical skills. Our surgical simulator was rated to be as useful as a cadaver head but is more readily available and cost effective.

Insights from mathematical modelling and quantitative analysis on the proposed 2030 goals for trachoma

Trachoma is a neglected tropical disease and the leading infectious cause of blindness worldwide. The current World Health Organization goal for trachoma is elimination as a public health problem, defined as reaching a prevalence of trachomatous inflammation-follicular below 5% in children (1-9 years) and a prevalence of trachomatous trichiasis in adults below 0.2%. Current targets to achieve elimination were set to 2020 but are being extended to 2030. Mathematical and statistical models suggest that 2030 is a realistic timeline for elimination as a public health problem in most trachoma endemic areas. Although the goal can be achieved, it is important to develop appropriate monitoring tools for surveillance after having achieved the elimination target to check for the possibility of resurgence. For this purpose, a standardized serological approach or the use of multiple diagnostics in complement would likely be required.

Effect of repeated epilation for minor trachomatous trichiasis on lash burden, phenotype and surgical management willingness: A cohort study

Background WHO endorsed the use of epilation as an alternative treatment to surgery for the management of both minor unoperated TT (UTT) and postoperative TT (PTT). However, some trachoma control programmes hesitated to implement epilation citing concerns that it would hamper TT surgical acceptance and result in larger numbers of and stiffer trichiatic eyelashes than the original TT lashes. We investigated the burden and phenotypes of post-epilation trichiatic eyelashes, and willingness to accept surgical management separately in unoperated and postoperative TT cases. Methodology/Principal findings We recruited cases with minor (≤5 eyelashes from the upper eyelid touching the eye or evidence of epilation in <1/3rd of the upper eyelid) UTT (170) and PTT (169) from community-based screenings in Amhara Region, Ethiopia. Participants eyes were examined and data on present and future willingness to accept surgical management collected at baseline and every month for 6-months. Eyelashes touching the eye were counted and their phenotypes documented. Participants were trained on how to epilate. Epilation was done by the participants at home and by the examiner during follow-ups when requested by the participant. Follow-up rates were ≥97%. There was evidence of a significant reduction in the burden of trichiatic eyelashes in unoperated (mean difference = -0.90 [-1.11– -0.69]; RR = 0.50 [95% CI, 0.40–0.62]; p<0.0001), and postoperative (mean difference = -1.16 [-1.36– -0.95]; RR = 0.38 [95% CI, 0.31–0.48]; p<0.0001) cases 6-month after frequent epilation. Post-epilation trichiatic eyelashes at 6-months had higher odds of being thin (40.2% vs 55.8%, OR = 1.88 [95% CI, 1.21–2.93]; p = 0.0048), weak (39.8% vs 70.8%, OR = 3.68 [95%CI,2.30–5.88]; p<0.0001), and half-length (30.9% vs 43.3%, OR = 1.71 [1.09–2.68]; p = 0.020) than the pre-epilation trichiatic eyelashes in unoperated cases. There was a significant increase in the proportion of weak trichiatic eyelashes (OR = 1.99 [95% CI, 1.03–3.83; p = 0.039) in postoperative cases. In all 6 follow-up time points, 120/164 (73.2%) of unoperated and 134/163 (82.2%) of postoperative cases indicated that they would accept surgery if their trichiasis progressed. Conclusions/Significance In this study setting, frequent epilation neither hampers surgical acceptance nor results in more damaging trichiatic eyelashes than the pre-epilation lashes; and can be used as an alternative to the programmatic management of minor unoperated and postoperative TT cases.

The magnitude and associated Factors of Postoperative Trichiasis among adults who underwent Trachomatous Trichiasis Surgery in Ambassel District, North-East Ethiopia

Background In Trachoma endemic countries, many people who underwent Trichiasis surgery faced a recurrence of the disease. Postoperative Trichiasis is a significant problem for patients and health care providers because it puts the eye at renewed risk of sight loss. Despite the low utilization of Trachomatous Trichiasis (TT) surgery and high recurrence rate, evidences that elucidate why TT recurs after surgery are limited. This study was aimed to assess the magnitude and associated factors of postoperative Trichiasis among 18 years and above individuals who underwent Trachomatous Trichiasis surgery between 2006 and 2011 Ethiopian Fiscal year in Ambassel District, North-East Ethiopia, 2020. Methods The community-based cross-sectional study design was conducted from March 10 to March 23/2020 in selected kebeles of Ambassel District. The required sample size was calculated using EPI-INFO Version 7. A multi-stage sampling technique was used to employ a total of 506 individuals. Data were collected through the interviewer-administered structured pre-tested questionnaire and entered into EpiData version 3.1 and then exported to SPSS version 23.0. Bi-variable and multivariable logistic regression models were fitted to identify associated factors of Trachomatous Trichiasis recurrence. Results Four hundred ninety two individuals participated in this study with response rate of 97.2%. In Ambassel district the prevalence of postoperative Trichiasis was 23.8% (95%CI = 19.9–27.8). Among associated factors of postoperative Trichiasis age 50–59 AOR = 3.34 (CI = 1.38–8.1), 60–69 AOR = 3.24(CI = 1.38–7.61), ≥ 70 years AOR = 6.04 (CI = 2.23–16.41), duration since surgery AOR = 1.7(CI = 1.35–2.14), complication AOR = 2.98(CI = 1.24–7.2), washing the face two times AOR = 0.25(CI = 0.13–0.47), washing the face three and more times AOR = 0.1(CI = 0.41 − 0.25), taking Azithromycin following surgery AOR = 0.19(CI = 0.09–0.41), pre-operative epilation history AOR = 2.11, (CI = 1.14, 3.9)and having a knowledge about TrachomaTtrichiasis AOR = 0.21(CI = 0.08–0.58) showed a statistical significant association. Conclusions The prevalence of postoperative Trichiasis in Ambassel District was higher than most Ethiopian studies. Age, frequency of face washing, medication following surgery, duration since the last surgery, knowledge about trachoma, pre-operative epilation history and complication after surgery were identified to be independent factors. To minimize postoperative Trichiasis stakeholders need to consider health education for patients, provision of Azithromycin after surgery and proper training for IECWs.