Recommendations: Trachoma and trichiasis
Preventive intervention type
Who is at risk?
What should be done?
Level/ strength of evidence
|People living where trachoma is endemic (>5% prevalence of active trachoma in young children or >0.1% of the population have trichiasis)
|Implement a community screening program in partnership with regional population health units to assess the population prevalence of active trachoma
Ongoing community screening is not required once prevalence is below 5% in children aged 5–9 years for five consecutive years
|As per national guideline recommendations (refer to ‘Resources’)
|Adults aged >40 years raised in trachoma-endemic area
|Perform eye examination to ascertain corneal scarring and/or the presence of trichiasis*
|Two-yearly age 40–54 years, yearly age ≥55 years
|74, 100, 101
|For those identified to have trichiasis, refer to an ophthalmologist for surgery
|All children from tracho-maendemic areas
|Recommend to families the importance of the following in the prevention and control of trachoma:
- facial cleanliness of children
- safe and functional washing facilities at home, in childcare and at school
- regular screening, and treatment of infection
|Opportunistic and as part of an annual child health check
|People living where trachoma is endemic (>5% prevalence of active trachoma in young children)
|Treat case and all household contacts, discuss with regional trachoma control program to plan and deliver treatment to community, depending on community prevalence/cluster pattern
Treat children who have been opportunistically found to have evidence of active trachoma infection and treat all household contacts
|As per state and territory protocols
|Assess the safety and functionality of the bathroom and washing facilities, and the housing situation for overcrowding, and refer to social support services for housing assistance if indicated (refer to Chapter 7: Hearing loss)
|Implement joint health promotion strategies with state/territory government public health units and local shire councils for maintaining functional washing facilities and other environmental health standards
|As per state/ territory government plans
|*Trichiasis is diagnosed when at least one eyelash rubs on the eyeball, or there is evidence of recently removed eyelashes because of eyelash in-turning.72
Trachoma is a bacterial eye disease associated with socioeconomic factors including overcrowding and poor community hygiene.70 Classification of trachoma is via the World Health Organization (WHO) simplified trachoma grading system. Active trachoma (defined as trachoma follicular and/or trachoma inflammation) predominantly affects young children, and is a contagious infection of the eye by specific, non-genital strains of the bacteria Chlamydia trachomatis. Multiple infections cause conjunctival scarring (trachomatous scarring) leading to eyelid contraction and in-turned margin (entropion) over decades (trachomatous trichiasis). The resulting in-turned eyelashes rub on the eyeball, causing painful corneal scarring and corneal opacity. It is estimated that some 150 to 200 episodes of reinfection may be necessary to lead to blindness.71 As most of this transmission occurs in childhood, children may be reinfected several times a month.
Trachomatous trichiasis is defined as at least one eyelash rubbing on the eyeball, or there is evidence of recently removed eyelashes because of eyelash in-turning.72 If not treated with surgery to the eyelid to correct in-turned eyelashes, corneal scarring can end in blindness in later adult life. This can occur 20–40 years after the initial trachoma infections. Trachoma is the leading infectious cause of blindness, with blinding trachoma the result of a complex interaction between the actual infection and immune response.70
Australia is the only high-income country in the world that still has pockets of endemic trachoma and trichiasis.73 This occurs almost exclusively in remote Aboriginal communities in the NT, South Australia and Western Australia. Trachoma is classified as endemic if >5% of children aged 5–9 years have active trachoma or >0.2% of adults or 0.1% of the whole population has trichiasis.74 The prevalence of active trachoma in children in the endemic areas has fallen from 21% in 2008 to 4.6% in the latest figures from 2015.75,76 Screening and treatment for trichiasis have not been reported in a systematic way in most Australian control programs,34 but with the advent of a National Trachoma Surveillance and Reporting Unit this is improving.77 In the communities screened in 2015 as a part of the National Trachoma Surveillance, the prevalence of trichiasis was 0.5% in adults aged >15 years, and 0.9% in adults aged >40 years; however, it is suspected that screening coverage in this age group was low.78
In Australia, community-wide screening occurs in communities that are identified as at risk. At-risk communities are identified by prevalence of active trachoma of >5% in Aboriginal and Torres Strait Islander children aged 5–9 years in the last five years; or current data showing <5% prevalence but >5% prevalence recorded in the last five years; or, where no data are available, historical evidence of endemic trachoma.
Evidence of the effectiveness of preventive interventions
Australia is committed to the Alliance for Global Elimination of Trachoma by 2020 (GET2020), and as a result has developed guidelines for management of trachoma. The Communicable Diseases Network Australia Guidelines for the public health management of trachoma in Australia, 2014,74 are based on the WHO SAFE strategy.70,74 The acronym SAFE encompasses an integrated approach to prevention, including Surgery for trichiasis and entropion; Antibiotics to reduce community levels of chlamydial infection; Facial cleanliness for children; and Environmental measures to reduce trachoma transmission. There is good evidence to support all SAFE strategy components.74 Chlamydia vaccine development has been flagged as a possible complementary strategy to SAFE, but is currently many years away.79
Facial cleanliness has been found to be linked with lower incidence of trachoma.70 Chlamydial infection is transmitted by sharing infected ocular and nasal secretions, so that every child with a dirty face is ‘a health hazard’. A clean face is defined as a face without dried ocular and nasal discharge. With the event of Australia’s commitment to GET2020, there have been health promotion initiatives in numerous remote communities to promote facial hygiene. Data from 2010 to 2015 indicates that the prevalence of facial hygiene is improving.80 Facial cleanliness can be promoted by a variety of methods, including by combining it with other hygiene practices such as nose blowing, hand hygiene and brushing teeth, and also by installation of mirrors so that children can see whether their face is clean.74 Facial cleanliness is not possible in the absence of functioning plumbing and washing facilities. Initial assessment of housing in 132 Aboriginal communities across Australia from January 1999 to November 2006 found that only 35% of households had a functioning shower.81 The Housing for Health project, a continuation of this assessment, has resulted in significant improvements in surveyed Aboriginal communities, resulting in a significant decline of the rates of trachoma in these communities.82–84 The Housing for Health project involved reviewing the housing hardware in certain communities using predetermined ‘healthy living practices’, reviewing this regularly and providing maintenance. Further detail can be found at Housing for Health (refer to ‘Resources’).82,83
Although flies, fingers and fomites are purported to be the three primary ways that trachoma is transmitted, the key is the transmission of infected ocular and nasal secretions from one child to another.85 As a result, environmental strategies, such as improved water access and safe and functional washing facilities or bathrooms, and reduced household overcrowding, play a key role in trachoma control.1,84,86
Within communities, trachoma is strongly clustered by households;32 and within households, clustered by sleeping rooms.33 This suggests continued transmission depends on close, prolonged contact. Close contact results in infected facial secretions spreading between people rapidly, allowing for the spread of Chlamydia trachomatis.87
Sanitation, as previously stated, is important in that it allows for facial cleanliness. Good sanitation also allows for the appropriate disposal of waste, preventing the build-up of flies.87 Although the provision of pit latrines has received much attention in African areas, subsequent work has shown that these have had little impact because most transmission occurs by the direct sharing of infected secretions.88,89 Access to appropriate laundry facilities prevents the spread of fomites via bedding and clothing.87 The Housing for Health project found that only 29% of assessed households had a laundry with services working, and 59% had a working toilet; with the project’s input into these communities, this has improved to 71% and 91% respectively.83 Australian studies have so far shown that fly population control and dust control have limited impact on the prevalence of trachoma;90,91 however, the long-term impact of such studies is unknown.92 Flies are believed to act as mechanical vectors, spreading nasal and eye secretions,93,94 with a review of studies largely performed overseas showing that measures to reduce fly populations by environmental improvements are associated with reductions in the rates of trachoma.95 Dust has also been implicated as a risk factor for trachoma.84,90 It is believed that dust causes eye irritation, resulting in rubbing eyes with fingers, discharge and inflammation.84 Dust control involves sealing roads, building of mounds and landscaping measures to protect from wind.84,90 However, as previously stated, in Australia the main emphasis should be on clean faces and access to safe and functional washing facilities.
With household spread and high mobility of families in remote areas, trachoma control and prevention may be better undertaken at a regional level with coordination of screening and mass treatment.74 In Australia, the transient migration of many members of remote communities may contribute to ongoing trachoma endemicity. Primary health practitioners have an important role in partnering with regional population health units to implement these programs, and they can be linked to other child health screening assessments (eg anaemia and nutrition assessments).
The diagnosis of trachoma is based on clinical grounds (refer to ‘Resources’: WHO trachoma grading card; University of Melbourne, Indigenous Eye Health online resources and training).
The ‘3Ts’ need to be remembered for the trichiasis examination:
Think to do it, use a Thumb to lift the lid so the lashes lift away from the eye, and use a Torch to provide enough light to see the dark lashes.
Laboratory tests to confirm trachoma infection are currently not recommended except perhaps to exclude other viral or bacterial infection.96 Although laboratory tests are improving, their cost and timeliness in providing a result remain significant impediments to routine use for trachoma screening.70 As a result, although clinical signs often persist beyond active infection, clinical examination remains the recommended tool for diagnosis.70
There is no evidence that opportunistic examination and treatment for trachoma in individual children improves community trachoma outcomes, but it may relieve symptoms or prompt/inform discussions about the need for treatment of households and mass treatment programs. If treatment is provided, it should be given to all people living in the same house(s) as the affected child.
The 2014 CDNA national guidelines for public health management of trachoma suggest that treatment of cases should be dependent on screening outcomes.74 Screening is recommended for Aboriginal and Torres Strait Islander children aged 5–9 years who are residents of the community based on school enrolments, child health nurse records and other sources. Treatment strategy is determined by the prevalence of active trachoma cases within the community at time of screening, and may involve treating all household contacts or mass treatment of the whole community. There may be a requirement for repeat treatments on an annual basis depending on the disease prevalence in the community.74 Should a spontaneous case be detected outside of community-wide screening, the index case and their household require treatment.74 There is strong evidence to support community-wide treatment/ mass drug administration in reducing the prevalence of trachoma.97,98
The decision to screen and treat individuals and their contacts should, therefore, be based on patient origin from endemic area, age and symptoms, as well as liaison with regional trachoma control programs. Discussion with regional trachoma programs will help in determining the frequency and extent of screening, as well as treatment regime.74
Aboriginal and Torres Strait Islander adults aged >40 years and who are current or past residents of remote communities should be screened annually for evidence of trichiasis as part of the MBS item 715 health check. This can be done by the primary care provider as part of an annual health assessment, and need not be part of community-based programs.74 All cases of trichiasis identified on screening or opportunistically should be referred for ophthalmological assessment.74 Blindness due to trichiasis is irreversible once it has occurred, but progression to blindness can be halted by surgery because it stops eyelash rubbing and therefore prevents corneal opacity.99 Surgery, however, does not necessarily stop further progression of trichiasis. Therefore, postsurgery, patients should be followed up annually to screen for recurrence.38 Other trichiasis complications such as dry eyes need symptomatic treatment to prevent further complications.
Although not a notifiable disease, data from screening should be de-identified and passed onto the National
Trachoma Surveillance and Reporting Unit by nationally agreed procedures.74
- Australian Indigenous HealthInfoNet, Eye health resources
- Australian Institute of Health and Welfare, Indigenous eye health measures 2016
- Centre for Eye Research Australia (CERA), Melbourne School of Population and Global Health, University of Melbourne, National Indigenous Eye Health Survey: Minum barreng (Tracking eyes) – Full report
- Communicable Diseases Network Australia (CDNA), CDNA Guidelines for the public health management of trachoma in Australia
- Department of Health, MBS Online, Medicare Benefits Schedule – Item 715: Aboriginal and Torres Strait Islander peoples health assessment
- Department of Health, MBS Online, Medicare Benefits Schedule – Item 12325: Aboriginal and Torres Strait Islander peoples assessment of visual acuity and bilateral retinal photography with a non-mydriatic retinal camera
- Housing for Health, Housing for Health: The guide, Information about the links between health and the living environment
- Indigenous Eye Health, Melbourne School of Population and Global Health, University of Melbourne
- Indigenous Eye Health, Melbourne School of Population and Global Health, University of Melbourne, Check today, see tomorrow resource kit
- Indigenous Eye Health, Melbourne School of Population and Global Health, University of Melbourne, Diabetes eye health: A guide for health professionals
- Lions Outback Vision, Diabetic retinopathy screening manual
- National Health and Medical Research Council (NHMRC), Guidelines for the management of diabetic retinopathy
- Vision 2020, Our work
- World Health Organization (WHO), Trachoma grading card, showing simplified trachoma grading system; includes high-quality clinical pictures of trachoma and trichiasis
- World Health Organization (WHO), Trachoma, Information on the global initiative to eradicate trachoma