trachoma: diagnosis, treatment, &...
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Trachoma: Diagnosis, Treatment, & Prevention
Melina Lopez
February 24th, 2012
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DIAGNOSIS OF TRACHOMA
UpToDate 2012
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DIAGNOSIS OF TRACHOMA u Active Trachoma-mostly seen in young children
u Cicatricial (scarring) complications and blindness- seen in late childhood and adulthood
UpToDate 2012
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DIAGNOSIS OF TRACHOMA
UpToDate2012
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DIAGNOSIS OF TRACHOMA
UpToDate 2012
The Centre for Eye Research, Australia and UpToDate 2012
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Trachomatous Inflammation Intense (TI)
DIAGNOSIS OF TRACHOMA
The Centre for Eye Research, Australia
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Progression of Trachoma and Cicatricial Disease: Conjunctival Scarring
DIAGNOSIS OF TRACHOMA
UpToDate2012
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DIAGNOSIS OF TRACHOMA
UpToDate2012
u Eyelid scar tissue can lead to inward rolling of the eye (entropion) and subsequent ingrown eyelashes (Trichiasis)
u Diagnosis of trichiasis is crucial as this should prompt surgical intervention to prevent scratching of the cornea and subsequent blindness
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DIAGNOSIS OF TRACHOMA
UpToDate2012
u The picture to the right depicts progression of Pannus, the growth of vascular tissue over the cornea due to edema and ulceration as a result of eyelash abrasion of the cornea u The bottom picture shows evidence of corneal opacification and loss of vision
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DIAGNOSIS OF TRACHOMA
UpToDate2012
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CLINICAL DIAGNOSIS DISADVANTAGES
u Over- or under- diagnosing à Overlooking asymptomatic
cases u Recovery phase of infection can
result in misdiagnoses à Clinical diagnosis before and after treatment
u Misallocation of treatment
following misdiagnoses HuffingtonPost.com 2009
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LABORATORY DIAGNOSTICS u Laboratory assays used for research studies and areas with low prevalence
u Nucleic Acid Amplification Test (NAAT)
u Highly specific u Used in areas with low prevalence u Not necessary in areas with higher prevalence because of higher correlation between disease and infection
UCSF.org
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Call for Point-of-Care Tests u Resources required for laboratory tests are expensive
u Clinical grading has remained the most common form of diagnosis because of this
u Many physicians and officials call for the development of a point-of-care test
u 2006 Tanzania: point-of-care test à Further development needed
University of Cambridge, 2011
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TREATMENT
Pfizer.com
u Mass treatment of antibiotics
u Azithromycin-single dose, preferred treatment u Tetracycline-1 percent eye ointment twice a day for six weeks
à lower compliance because daily administration and many doses
http://labspace.open.ac.uk/mod/oucontent/view.php?id=452781§ion=1.3.5
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TREATMENT u Mass treatment of azithromycin specifically has brought up questions of antibiotic resistance
u Chlamydial resistance to azithromycin has not been documented thus far
u At the same time, while azithromycin may not cause bacterial resistance for Trachoma, resistance has developed due to other bacterial infections including S. Streptococcus u Overall, however, Azithromycin has proven to reduce mortality in children due to its protection against other pressing infections
Liquidized form of azithromycin. Picture compliments of CarterCenter.org
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TREATMENT u Surgical intervention for trichiasis, followed by topical ointment for seven days after surgery
u Bilamellar tarsal rotation to direct the lashes away from the globe
àEarly intervention for both major and minor trichiasis
u Epilation (eyelash removal)
u Short-term eyelid taping u No vaccine is currently available, however, research is underway
http://www.ntd-ngdonetwork.org/diseases.php
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IDENTIFY NEED FOR INTERVENTION u Gold Standard PBPS: Population
Based Prevalence Surveys u Collect previous surveys, written
reports, hospital eye surgery records and interview people with local experience
u Identify water access and latrines in community
u Random sample representative cluster u Alternate methods: trachoma rapid
assessment (TRA) and acceptance sampling TRA (ASTRA).
Conducting a household survey. Picture on behalf of Global Health Institute-University of Wisconsin-Madison, 2007.
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IDENTIFY NEED FOR INTERVENTION
WHO 2006 Report
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INTERVENTION u Remember high risk population is children <10 years old
u “Herd immunity” gained by administering azithromycin to children
u Even though, remember at least 80% population needs to be treated http://www.nei.nih.gov/news/
scienceadvances/discovery/trachoma.asp
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PAST INTERVENTIONS-THE US u With large waves of immigration in the 20th century, the US prohibited immigrants from entering the US if they were infected with Trachoma u Early 20th century US Anti-Trachoma legislation to control infection, especially in Indian reservations u As a result of this legislation, subsequent improved housing and living standards, Trachoma is no longer is a major public health threat in the US http://www.ellisisland.org/
photoalbums/ellis_island_then.asp
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INTERVENTION u In addition to antibiotic
treatment, think of the environmental risk factors of trachoma to prevent infection and possible re-infection:
u The 6 D’s: Dryness, dust, dirt, dung, discharge, density (overcrowding)
u The 5 Fs: flies, feces, faces, fingers, and fomites CarterCenter.org
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INTERVENTION Targeting the Mechanical Vector Targeting Human Transmission
http://developmentmedia.net/success.html http://bjo.bmj.com/content/88/6/750.full
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PREVENTION IN CRISISES
u Sanitation and Hygiene
u Contain fecal matter in latrines to limit fly population
u Include azithromycin in proposed “medical cocktail” of Ivermectin and Albendazole to prevent the seven neglected tropical diseases
http://www.msf.org.au/uploads/pics/Refugee_camp_bannon_01.jpg
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CURRENT PREVENTION: S.A.F.E.
S: simple surgery to create a slit in the eyelid and peel back a portion to prevent further corneal scarring. A: antibiotics. Single dose of azithromycin F: facial hygiene. Face washing, especially among children who may be outdoors playing with many other kids, is a great step in interrupting transmission. E: environmental empowerment. Improve access to clean water, improve sanitation and latrines to reduce fly populations. Educational empowerment for community members also lends them the ability to prevent human-human transmission by better hygiene.
Management & Prevention Strategy as outlined by WHO and ITI:
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MOROCCO 1999: MANAGEMENT AND PREVENTION SUCCESS STORY!
u 5 government ministries partnered, including health and education, local NGOs and international organizations such as UNICEF and WHO
u Mobile surgery units u Administer Zithromax u Build wells and latrines u Provide education u SAFE strategy
ITI Morocco Report
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TRACHOMA ELIMINATION u 1997: WHO Alliance for the Global Elimination of Blinding Trachoma (GET 2020) created
u Greater Implementation of SAFE strategy
u Proven evidence of the effectiveness of mass treatment u àCase study in Tanzania
u Development of Point-Of-Care Tests
u Greater education