Trachoma and trichiasis

• Undertake training in correctly identifying trachoma and trichiasis.
  • Self-learning modules are available through Remote Area Health Corps (see Useful resources)
  • Organise in-service professional development sessions with your regional public health unit.
• Partner with your regional public health unit to support the local control program. A map is available within the Australian trachoma surveillance report with the latest prevalence figures per health region in each state and territory.⁴
• Regarding annual trichiasis checks:
  • ensure your practice software system has an annual recall in place for trichiasis screening for adults aged 40 years and older who grew up in a trachoma endemic area.
• Regarding surgical referrals:
  • consider establishing reminder systems for those patients who have been referred for surgery to discuss and ensure safe pain management options while they are on the waiting list.
• Regarding epilation:
  • ensure you discuss the advantages and disadvantages of epilation; it should not be a replacement for surgery, but a temporary measure while waiting for surgery
  • encourage people to come to the clinic so you can do it for them (if you have the skills/training and appropriate equipment)
  • if in doubt, ask the regional optometrist or ophthalmologist to demonstrate how best to epilate eyelashes during their next visit to the community.
• Regarding environmental checks:
  • ask questions sensitively during the annual health check, such as whether patients have any plumbing problems, whether the taps are leaking, whether the washing machine is working or whether they have anything that needs fixing. You can use this information to write a referral to the environmental health officer or housing and social department according to your jurisdictional protocols.
• Undertake clinical audit in at-risk/trachoma endemic communities using indicators such as:
  • 85% of people aged over 40 years have been screened for trichiasis in the previous 12 months
  • 85% of household contacts of active trachoma cases were treated with antibiotics within one week of commencing treatment within that household.²

• Trachoma Communicable Diseases Network Australia (CDNA) national guidelines 
• Queensland communicable disease control guidance 

• Kirby Institute: Latest prevalence and geographic distribution of trachoma 
• Remote Area Health Corps: Self-directed online training   
• Housing for health – the guide: Importance and impact of adequate environmental and housing conditions for health 
• HealthInfoNet: Additional reading on trachoma and trichiasis 

Background

Trachoma is a disease of the eye caused by chronic inflammation of the conjunctiva from repeated infection with the bacteria Chlamydia trachomatis. It is important to note that the strains of C. trachomatis associated with trachoma differ from those associated with genital infection.¹

There are two main stages of trachoma: active/inflammatory and scarring (cicatricial/late).

Active trachoma, characterised by an inflammatory response, is diagnosed clinically using the World Health Organization (WHO) simplified grading system⁹ and can often be asymptomatic.² Active trachoma is usually seen in young children and adolescents.

The scarring or late phase of trachoma is the result of repeated infections leading to long-term inflammation, scarring of the tarsal conjunctivae, entropion (inward turning of the eyelid margin), and progression to trichiasis (eyelashes rubbing on the surface of the eye). Over time, the constant abrasion experienced in trichiasis can cause irreversible corneal opacity and blindness. This can be further complicated by secondary bacterial or, rarely, fungal infections.¹ Trichiasis, corneal opacities and blindness most commonly occur in adults aged over 40 years.²

1. trachomatis is mainly spread by infected ocular and nasal secretions passed between young children while playing, touching each other’s faces, sharing beds, towels or face cloths, coughing or sneezing and by eye-seeking flies.²

Globally, trachoma is responsible for the blindness or visual impairment of approximately 1.9 million people, making it the leading infectious cause of blindness worldwide.¹ Trachoma is endemic in many of the poorest and most rural areas of Africa, Central and South America, Asia, the Middle East and in some remote Aboriginal communities in Australia.¹ Australia is the only developed country with endemic trachoma.

In Aboriginal and Torres Strait Islander communities, trachoma is defined as endemic when 5% or more of children in the community aged 5–9 years have active trachoma or 0.1% or more of adults in the community have trichiasis.²

Although the estimated prevalence of active trachoma in children aged 5–9 years screened across all Aboriginal and Torres Strait Islander at-risk communities has dropped from 15% in 2009 to 3.3% in 2021, trachoma remains a significant public health concern in the Northern Territory, South Australia and Western Australia, where prevalence in some remote Aboriginal and Torres Strait Islander communities was reported to be as high as 15% in 2019.³

The mode of transmission and the natural progression of the disease from multiple infections to blindness offer plenty of opportunities for preventive action at the primordial, primary, secondary and tertiary levels. These are summarised by the SAFE (Surgery, Antibiotics, Facial cleanliness and Environmental improvement) strategy (see Preventive activities), which was adopted by the WHO in 1993 and has remained unchanged since then.¹

As a member of the WHO Alliance for Global Elimination of Trachoma by 2020 (WHO GET2020), Australia is committed to implementing the SAFE recommendations in communities at risk of trachoma.¹⁰ These recommendations have been included in the CDNA national guidelines for the public health management of trachoma² and were discussed in the third edition of this guide.¹¹ The new target date for global elimination of trachoma is 2030, as outlined in the WHO road map for neglected tropical diseases 2021–2030.¹²

In this new edition of the National Guide there is greater emphasis on actionable preventive measures by clinicians working in remote communities at risk of trachoma and trichiasis, such as advocating and referring patients for services that improve their housing and living conditions.

SAFE strategy

The SAFE acronym encompasses an integrated approach to prevention, with each component targeting a different stage of the disease. However, the different measures are discussed below in order of level of prevention (E-F-A-S).

E: Environmental improvement (primordial prevention)

Children are the main reservoir of trachoma in families and communities; they are often asymptomatic and remain infectious for two to three months after each active infection.² Environmental improvements should focus on actions that:

• enable children to wash their hands and faces frequently, with access to clean and functioning water supplies
• promote education and self-efficacy, such as access to mirrors near washing basins so that children can do their own assessment of how clean their faces are
• interrupt the chain of transmission, such as access to clean linen and aired mattresses, and attempts to reduce fly density (eg by adequate waste disposal, rubbish bin collection and rubbish tips located at a distance from the community).

Although it may not be within the clinician’s scope of practice to conduct house checks and provide the required environmental infrastructure, primary care clinicians can play a critical role in advocating for the rights of their patients to have access to a clean and safe water supply and improved housing conditions. Clinicians are encouraged to ask their patients about their environmental and living conditions. This can be included, for example, in annual health checks (eg Medicare Benefit Schedule Item 715). Asking about environmental and living conditions provides an excellent opportunity for community members to regularly voice concerns regarding the suitability and functionality of washing facilities at home, plumbing issues and other problems in their bathroom and laundries, for example. When appropriate and available, the clinician can complete a referral to environmental health officers to visit the home, provide education and resources to enable hygiene practices and arrange for any repairs that are required, following jurisdictional procedures.

The significance of improving environmental and housing conditions should not be underestimated by the difficulties in achieving them. Safe and functional living conditions are not only a basic human right, but also a primordial preventive measure for other diseases, such as scabies, otitis media, rheumatic fever and gastrointestinal infections, which share similar risk factors.²

F: Facial cleanliness (primary prevention)

Having a clean face is defined as the absence of nasal and ocular discharge,¹³ and this has been found to be a protective factor against trachoma.¹⁴ As a result, for decades efforts have been put into health promotion messages and education about the importance of having a clean face. However, a recent systematic review of 33 Australian studies found no evidence to suggest a statistically significant benefit on trachoma prevalence from a particular frequency or technique of face washing, or even education programs about face washing.¹⁵ Another study of over 3000 children in Tanzania also found that health messages and materials on trachoma were not associated with clean faces or lower rates of trachoma in the community.¹⁶ An important finding of the systematic review in Australia was that sanitation infrastructure in the community is the key determinant of facial cleanliness.¹⁵

Although the value of health promotion and education is undisputable, this guide calls for a change in the content and tone of messages. Community awareness about trachoma, how it is spread and how it can be prevented should be raised in a non-paternalistic way that supports community self-determination and empowerment to demand the right environment to achieve trachoma elimination.

A: Antibiotics (secondary prevention)

(See also Trachoma screening below)

The antibiotic treatment of individuals with active trachoma, and their contacts, with single-dose azithromycin plays a significant role in decreasing the prevalence of trachoma by reducing the pool of infection circulating in the community.² In some situations, where prevalence on screening is high, state and territory trachoma control programs will recommend and implement community-wide treatment within a two-week period.² Decisions to implement community-wide treatment requires consultation and agreement between the community, health service and public health unit. 

Within communities, trachoma is strongly clustered by household. Within households, trachoma is clustered by sleeping room.¹⁷ Therefore, antibiotic treatment of household contacts (anyone living and/or sleeping in the same household as a person with trachoma) is important to eliminate disease carriage and ongoing transmission from asymptomatic individuals.² A household contact is defined as:

…anyone who is living and/or sleeping in the same household as a person with trachoma. If the active case lives or sleeps in multiple households, then members of all households in which the active case stays are considered contacts.² 

Opportunistic screening outside of coordinated trachoma control programs is not recommended. However, if an individual presents to the clinic with symptoms indicating trachoma, the individual should be examined and, if trachoma is diagnosed, the case and their contacts (excluding infants who weigh less than 3 kg) should be treated at the same time with single-dose azithromycin (see Appendix 4 of the CDNA guidelines²).

S: Surgery (tertiary prevention)

(See also Trichiasis screening below) 

The WHO recommends surgery for all patients with trachomatous trichiasis, even if only one eyelash touches the eye.¹⁸

Surgery is effective in reducing the short-term effects of trichiasis (eg pain and photophobia), as well as the long-term effects of corneal scarring and blindness.¹⁹ However, it does not provide a definitive cure. The natural progression of the disease may lead to recurrence,²⁰ in which case repeat surgery is required.

People living in remote communities often experience significant delays in accessing surgery²¹ and, as such, temporary pain relief strategies may need to be considered.

Trachoma screening (secondary prevention)

The CDNA guidelines recommend annual population-based screening of active trachoma in Aboriginal and Torres Strait Islander children aged 5–9 years who are in at-risk communities at the time of screening.²

At-risk communities are those with:

• no recent data, but historical evidence of endemicity
• active trachoma prevalence ≥ 5% in Aboriginal and Torres Strait Islander children aged 5–9 years in the past five years
• <5% active trachoma prevalence but with a recorded prevalence of active trachoma ≥5% in the past 5 years.²

In these communities, current guidelines do not recommend primary health services undertaking opportunistic screening of individuals or households. Instead, the regional public health unit will have implemented a coordinated trachoma control program, including community education, environmental health assessments and trachoma screening.^2,4

In areas where trachoma is not known to be endemic, symptomatic individuals should be examined for trachoma and, if trachoma is diagnosed, the patient should be treated, along with their household contacts, and this treatment well documented. The local public health unit should also be notified of the case because wider community screening may be indicated.²

Trichiasis screening (tertiary prevention)

Screening for trichiasis involves the 3Ts:

• Think to do it
• use a Thumb to lift the lid so the lashes lift away from the eye
• use a Torch to provide enough light to see the dark lashes.

Diagnosis is made once the clinician identifies at least one eyelash touching the globe.⁹

Unlike screening for active trachoma, screening for trichiasis should be conducted on an individual rather than community level and incorporated into the ongoing activities of the community primary healthcare team.²

The CDNA guidelines recommend that Aboriginal and Torres Strait Islander adults aged over 40 years and who resided in a remote community during childhood should be screened annually for trichiasis by primary healthcare providers either opportunistically or as part the annual check (Medicare Benefit Schedule Item 715). It is important to continue to screen adults regularly because trichiasis is an indolent, slowly progressing condition,² including patients who have already received surgery for trichiasis because of risk of recurrence.²⁰

Staff in aged care services, hostels and nursing homes should be educated so they are aware of trichiasis and are encouraged to refer patients with irritated or watery eyes to primary healthcare services for confirmation and further referral for eyelid surgery if required.²

Epilation

Ophthalmological consultation is recommended for all people with trichiasis.

For those patients who decline surgery, the WHO has recommended epilation, which involves removal of the eyelash by the patient, a carer or a health professional.⁵ This practice is often undertaken by patients as a way of self-managing pain and discomfort before seeing the doctor or while waiting for surgery.²²

Although epilation is generally perceived as a relatively harmless practice, incomplete epilation and broken lashes can produce more corneal damage if the stump left behind continues to rub the corneal surface.²³ There is some suggestion that it may also increase the risk of postoperative trichiasis,⁶ although more evidence is needed. It is also important to note that lashes will regrow within four to six weeks; therefore, epilation may need to be repeated.²⁴

The CARPA manual recommends that clinicians do not pull out inward turning eyelashes, unless a stubble is visible from a previously pulled out eyelash.²⁵ However, the CDNA guidelines recommend that epilation may be used as a temporary measure to prevent progression to opacity and scarring while the patient is waiting for surgery, or as a last resort if the patient refuses surgery.²

Given the concerns regarding corneal damage due to broken lashes as a result of inadequate epilation,²⁶ it may be reasonable for clinicians to offer to remove an eyelash or two for their patients, using a slit lamp, head loupe or a torch to ensure good visibility, as well as forceps applied at the lid margin to ensure full removal of the lash. Patients should also be advised the lash will regrow in four to six weeks²⁴ and therefore they may need to return for repeat epilation if they are still waiting for ophthalmology review.

Eye lubricants

Eye lubricants have also been suggested as temporary pain relief management options while waiting for surgical correction of trachomatous trichiasis;²⁷ however, if the offending eyelash is still present, the eye drops would have to be applied multiple times every day, which is neither practicable nor cost-effective.