Trachoma Pakistan

National Trachoma Survey
REPORT 2011-2013
Dr. Muhammad Zahid Jadoon

1. Executive Summary ................................................................................... 1
2. Introduction............................................................................................... 2
3. Objectives: ................................................................................................. 4
4. Methodology ............................................................................................. 5
3.1 Study design: Cross sectional descriptive .................................................. 5
3.2 Sample size .................................................................................................................. 5
3.3 Sampling Strategies ...................................................................................................... 5
3.4 Equipment.................................................................................................................... 6
3.5 Logistics/Transport ..................................................................................................... 6
3.6 Teams compositions ..................................................................................................... 6
3.7 Selection of districts ...................................................................................................... 6
3.9 Trainings ...................................................................................................................... 8
3.10 Quality assurance ....................................................................................................... 8
5. Ethical Approval ........................................................................................ 8

6. Services Provision ...................................................................................... 8
6. Results .......................................................................................................... 8
6.1 Summary of results from the previous phases.......................................... 9
6.1.1 Phase1 (15 Villages were surveyed) ............................................................................ 9
6.1.2 Key finding of Phase 1 ..............................................................................................10
6.1.3Phase 2 ......................................................................................................................10
6.1.4 Key Findings ............................................................................................................11
6.2 Results from the current Phase - Punjab............................................... 11

6.2.1 District Mianwali ....................................................................................................11
Water Supply ( Total House holds 1525) ..........................................................................12
6.2.2 District Bhakkar .......................................................................................................13
Status of Trachoma ..........................................................................................................13
6.2.3 Bahawalpur .............................................................................................................14
6.3. Sindh .................................................................................................... 16

6.3.1 District Sanghar ........................................................................................................16
6.3.2 District Badin ...........................................................................................................17
6.4 Baluchistan ............................................................................................ 19

6.4.1 Gawadar ..................................................................................................................19
6.5Gilgit Baltistan ........................................................................................ 20

6.5.1 District Astore ..........................................................................................................20
7.Conclusions ................................................................................................. 22
8. Recommendations....................................................................................... 22
9. References................................................................................................... 22
1. Executive Summary
Trachoma is the leading cause of blindness worldwide. Overall it is the eight commonest
cause of blindness. It is estimated that approximately 1.3 million people are blind from this
disease and probably a further 1.8 million have low vision. Trachoma is endemic in more
than 50 countries, predominantly in sub-Saharan Africa, the Middle East, and Asia
The burden of trachoma on affected individuals and communities can be huge both in terms
of the disability it causes and the economic costs that result. There is a worldwide effort
underway to try to control blinding trachoma; this is lead by the World Health Organization
(WHO) with the Global Alliance for the Elimination of Blinding Trachoma (GET2020).
The national program for prevention of blindness has also taken the initiative of eliminating
trachoma for the country. In this regards a phased survey has been initiated.
Objectives
To estimate the prevalence of TF/ TI amongst children age 0 to 9 years
To estimate the prevalence of TT amongst adults age 15 years and over
The WHO recommended methodology for epidemiologic survey was adopted for this
purpose. And trachoma was also graded using standard WHO criteria.
3 districts form Punjab, 2 from sindh one each from Baluchistan and Gilgit Baltistan were
chosen for this purpose.
Results
The prevalence of trachoma was very low within these seven districts. Only District Astore
in Gilgit Baltistan had prevalence about 1%. Rest of all district had prevalence below 0.5%.
No significant Trahomatous trichisis was found in these districts. Risk factor could not be
correlated due to the very low no of trachoma subjects, yet clean water supply, sanitation
and personal hygiene were major problems in these districts.
Conclusions & Recommendations

The prevalence of Trachoma in District Astore was about 1% , it is recommended on a
medium priority for the distribution of antibiotics within high risk groups.
It is very important to develop intersectoral linkages for the environmental cleanliness and
clean water supply.
2. Introduction
Trachoma is the leading cause of blindness worldwide. Overall it is the eight commonest
cause of blindness1. Trachoma is caused by the obligate intracellular bacterium C.
trachomatis. Recurrent episodes of conjunctival infection and the associated chronic
inflammation it causes initiate a scarring process that ultimately leads to irreversible
blindness.
It is estimated that approximately 1.3 million people are blind from this disease and
probably a further 1.8 million have low vision 2. Trachoma is endemic in more than 50
countries, predominantly in sub-Saharan Africa, the Middle East, and Asia
Today, blinding trachoma is believed to be endemic in 56 countries3. The countries with the
highest prevalence of disease are in sub-Saharan Africa, particularly in the Sahel belt and
East Africa. In addition, there are countries in the Middle East, the Indian sub-Continent,
and Southeast Asia where trachoma is endemic, although the distribution is patchier. One
hundred years ago trachoma was widespread in Europe and North America, but faded away
during the first half of the 20th century as living conditions improved 4.
Pathogenesis and Clinical Features

Endemic trachoma is caused by the four ocular serovars of C. trachomatis (A, B, Ba, and C).
Although the genital serovars (D to K) of C. trachomatis can infect the conjunctiva causing
either ophthalmianeonatorum in infants or inclusion conjunctivitis in adults these are
usually isolated episodes for the individual, which do not lead to blinding sequelae. For
endemic trachoma the average age of acquisition of the first episode of C. trachomatis
infection is probably related to the prevailing level of infection in the community. In
hyperendemic settings infection may be acquired in early infancy, whereas in meso- and
hypo-endemic regions it is probably on average later. Infection is probably usually acquired
through living in close physical proximity to an infected person, with the family as the
principle unit for transmission 5,6.
Conjunctival infection with C. trachomatis is largely confined to the epithelium, with little
evidence of deeper spread. The infection triggers an immune response characterised by a
marked inflammatory cell infiltrate and the release of pro-inflammatory cytokines in the
conjunctiva7,8. Clinically it causes papillary and/or follicular inflammation of the tarsal
conjunctiva, referred to as active trachoma . The WHO Simplified Trachoma Grading
System (Table 1), which is used by trachoma control programmes, subdivides active
trachoma into two often coexisting clinical phenotypes: Trachoma Inflammation Follicular
(TF) and Trachoma Inflammation Intense (TI)9.
Table 1. The WHO simplified system for the assessment of trachoma 8
National Trachoma Survey 2

Eventually the infection resolves and the clinically visible inflammation gradually subsides.
Animal models for C. trachomatis infection and limited data from humans indicate that the
resolution of infection is probably through an interferon-γ (IFN-γ)–dependent cell-mediated
immune response10,11. Studies from trachoma endemic communities have found that the
prevalence and duration of conjunctival chlamydial infection decline with increasing age,
suggesting that there is a maturation of the immune response as individuals are repeatedly
exposed to infection12,13. However, in the early vaccine trials using whole C. trachomatis
organisms the acquired immunity appeared to be strain specific and relatively short-
lived14,15,16 .
As a result of the relatively ineffective immune response, repeated infection of the individual
by Chlamydia trachomatis is common within an endemic environment. This leads to a
recurrent chronic inflammation, which is associated with the development of scar tissue
within the conjunctiva over many years 17,18
As the scar tissue accumulates it also contracts, causing the eyelids to roll inwards towards
the eye (entropion) and the eyelashes to scratch the ocular surface .
The most serious disease sequela from trachoma is blinding corneal opacification. The
main aetiological risk factor for corneal damage is the presence of trichiasis, however, a
number of other factors probably contribute such as bacterial infection and chronic
conjunctival inflammation 19.
The clinical manifestations of trachoma change with age. Active trachoma is predominantly
seen in young children, becoming less frequent and shorter in duration with increasing age
13,14
. Conjunctival scarring accumulates with age, usually becoming evident in the second or
third decade of life20,21. Entropion, trichiasis, and CO develop later.
The onset of the blinding complications of trachoma can occur in children living in regions
where the pressure of infection is high 22.
Epidemiological surveys have generally found trichiasis and CO to be more common in
women than men25,23. This difference has been attributed to the greater life time exposure of
women to C. trachomatis infection, through closer contact with children, the main reservoir
of infection.

The transmission of C. trachomatis from infected to non-infected individuals is necessary to
sustain trachoma in endemic communities. Several routes of transmission are probably
involved including direct spread (close contact), fomites, and eye-seeking flies. In common
with other Neglected Tropical Diseases (NTDs), trachoma is generally a disease of poor
rural communities. Risk factors for trachoma are generally things that favour the
transmission of C. trachomatis from one person to another 24.
 The presence of secretions around the eyes has consistently been associated with
active trachoma, attracting flies, and providing a vehicle for transmission.
 Similarly, water scarcity probably promotes transmission, because less water is
available to use for face washing.
 Limited access to latrines increases faecal contamination of the environment,
providing breeding material for the fly Muscasorbens, which is implicated in trachoma
transmission25.
 Crowded living conditions, for example with several young children sleeping in the
same bed, probably promotes transmission.
For many trachoma endemic countries the socioeconomic developments that might
promote the disappearance of the disease are likely to be very slow in arriving, which in
the light of demographic trends and in the absence of effective control programmes was
predicted to lead to an increase in the total numbers blind from trachoma26
The burden of trachoma on affected individuals and communities can be huge both in terms
of the disability it causes and the economic costs that result. There is a worldwide effort
underway to try to control blinding trachoma; this is lead by the World Health Organization
(WHO) with the Global Alliance for the Elimination of Blinding Trachoma (GET2020).
Eye Health in Pakistan

Pakistan has an exemplary eye care program led by the National steering committee.
Reduction in prevalence of blindness to half within 12 – 15 years time is one of its biggest
achievements. Other achievements include conduction of nation wide Trachoma Rapid
assessment followed by SAFE strategy implementation in trachoma endemic areas.
National Trachoma Survey

In alliance with GET 2020 to eliminate trachoma for Pakistan the National Committee for
eye health constituted a task force. For this purpose, the National committee and the
Trachoma task force agreed to initiate a country wide Trachoma survey to have a baseline
information for implementation of SAFE strategy wherever its needed and to eliminate
trachoma from the country by cby 2015.
3. Objectives:
To estimate the prevalence of TF/ TI amongst children age 0 to 9 years
To estimate the prevalence of TT amongst adults age 15 years and over

4. Methodology
3.1 Study design: Cross sectional descriptive
3.2 Sample size

WHO reccomends to use different sample sizes for TF/T1 in children and TT in Adults.
Sample size for ActiveTrahcoma(TF/TI) the sample
size is calculated on the basis of the prevalence of TI with lower expected prevalence then
TF. For an expected prevalence of 5% with 25% precision, 95% CI , an additional 5% for
the non responders and a design effect of 1.5%, the required sample size was 3500.from 35
clusters
To examine 3500 children (100 subjects from each cluster), 35 clusters were selected from
each district.
Sample size for TT
For expected prevalence of 1% with 30% precision, 95% CI , an additional 5% for the non
responders and a design effect of 1.5%, the required sample size was 7000 subjects tobe
examined from 70 clusters ( 100 subjeects from each cluster)
3.3 Sampling Strategies

A multistage cluster random sampling methods based on population proportionate to size
methodology was used for the selection clusters.
The survey was planned to be conducted in all districts of Pakistan . to start with the
districts were selected based on the report of Trachoma Rapid Assessment conducted in
year 2002 in Pakistan. Care was taken to include district classified as High, medium, Low
Priority and no priority in the previous TRA exercise.
10,500 subjects (3500 children and 7000 adults) were included from 70 clusters within each
district. Children were examined from every alternative cluster from the list of 70 selected
clusters from the district.
Selection of Households within villages.
Houses were selected from each village usingsystematic sequential sampling method based
on the sampling interval, calculated by dividing the total number of households in the
villages by the number of households required to be examined. This was done in advance
by the enumerators.

1 cluster was completed in one day. One district took approximately a 105 working days,
depending upon the number of teams.
3.4 Equipment
1. Torch
2. Binomac 2.5X
3. Shoulder Bag
4. Stationary (Pencils/sharpners/erasers/papers/forms)
5. Firstaid box
6. Caps
7. Umbrella
8. Water cooler
9. Medicine for sample subjects ( Tetracycline eye ointment, Azithromycin capsules
and suspensions)
3.5 Logistics/Transport
A car was hired for each team for their transportation between and within the clusters. Each
team was required to finish one cluster in a day’s time.
3.6 Teams compositions

 One Doctor (MBBS) (trained in diagnosis of TF/TI and TT with the help of torch
and Binomac).
 Two Enumerators .
 One Driver
 One Local village volunteer
3.7 Selection of districts

It was decided to include all districts and the survey be completed in a phased manner.
Districts in for each phase were selected with the consensus of the trachoma task force.
The following factors were considered to priorities districts for each phase.
1. Whether the district had the SAFE strategy implemented as a results of the
Trachoma Rapid Assessment in 2002.
2. Whether the district was included in the TRA in 2002.
3. The socioeconomic status of the district.
4. Geography and the climatic conditions of the districts.
5. The district health indicators.
3.7.1 First Phase (15- Districts)

This phase was jointly sponsored by ADP Scheme in Punjab and Sight savers in other
provinces.
 Punjab, under the Provincial PCB Program / ADP Scheme / Sightsavers (06-
Districts). i.eHafizabad, Narowal, DG Khan, Vehari, Bahawalnagar and Attock.
 Sindh, KPK &Balochistan in Collaboration with the Sightsavers (03, 03 & 02-
Districts).
 Sindh,:Thatta, Tharparkar and Shadakot
 KPK: DI khan, Chitral and Batagram
 Baluchistan ;Panjgur and pishsin
 GilgitBaltistan :Skardu (in collaboration with the CBM / CHEF Int’l )
The data was managed and anlysed in College of Allied Vision Sciences Lahore.
3.7.2 Second Phase (16 Districts)
The second Phase was sponsored by Sight Savers only.
The Trachoma Survey in additional 16-Districts of Pakistan has been accomplished..

Punjab (08): Sialkot, Okara, Kasur, Jhelum, Jhang, Sheikhupura+Nankana, Toba Tek
Singh and Chakwal.
Sindh (06): Khairpur, Jacobabad, NosheroFeroze, Dadu, Kashmore & Nawab Shah.
Khyber Pakhtunkhwa (01): Swabi
Balochistan (01): Uthal (Las Bella)
Data was managed and analysed at Pakistan Institute of Community Ophthalmology

Peshawar.
3.7.3 Third Phase (7 Districts)
The third phase is sponsored by Fred Hollows Foundation.
Punjab: MianwaliBhakkar and Bahawalpur

Sindh :Sanghar and Badin
Baluchistan: Gawadar
GilgitBaltistan: Astore

3.9 Trainings
A group of master trainers was identified which included an epidemiologists, a community
Ophthalmologist and an Ophthalmologist to train the survey teams.
A 2 days training was conducted in each province for their relative teams.
The teams were trained for diagnosis if trachomatous conditions and to classify them
according to the WHO standards. The teams were supplied with cards which had
photographic explanation the classification of trachoma according to the WHO standards.
The eligibility criteria was explained to the teams and the enumerators were trained on
sampling within the villages and careful enumeration.
The ophthalmologists were also trained on filling the survey forms with al the dos and
don’ts.
3.10 Quality assurance

The group of master trainers continuously monitored and the teams in the field and any
errors found were corrected there and then.
The team of master trainers continuously monitored the survey. Most of the time their
diagnosis were reconfirmed during these visits.
5. Ethical Approval
Ethical approval for the survey was obtained from the National steering committee.
(National Committee for prevention of Blindness).
Oral verbal consent was obtained from subjects 18 and above and from guardian/parents of
18 years and below subjects.
6. Services Provision
All positive cases for active Trachoma i.e trachoma intense or follicular were provided with
a complete dose of Azithromycin capsules/ suspensions.
Subjects with Trachomatous trichiasis were referred to the hearest district hospital for free
surgery.
6. Results
For Analysis purpose the TF and TI grades of trachoma were grouped as “Active
Trachoma”. The environmental risk factors were analysed at house hold level, a house was
defined as affected if one or more cases of any grades of trachoma were found.

6.1 Summary of results from the previous phases
6.1.1 Phase1 (15 Villages were surveyed)
PUNJAB
CHILDREN ADULTS
Active Active Trachomatous trichiasis Tr. Corneal Opacity
Trachoma(TF/TI) Trachoma(TF/TI) Sacarring
Hafizabad 57 ( 1.6%) 9 (0.13%) 17 (0.39%) 0 0
Narowal 55(1.57%) 0 71 (1.01%) 12 (0.17%) 4 (0.06%)
DG KHAN 17 (0.49%) 0 54 (0.77%) 0 0.16
Vehari 6(0.17%) 0 26 (0.36) 0 0
Bahawalnagar 0 0 3 (0.04%) 0 0
Attock 9 (0.26%) 0 6(0.09%) 8(0.11%) 0
BALUCHISTAN
CHILDREN ADULTS
Active Active Trachomatous Tr. Corneal Opacity
Trachoma(TF/TI) Trachoma(TF/TI) trichiasis Sacarring
Panjgur 10(0.29%) 0 4(0.06%) 0 0
Pishin 33(0.94%) 0 33(0.47%) 1(0.01%) 1 (0.01%)
SINDH
CHILDREN ADULTS
Active Active Trachomatous Tr. Corneal
Trachoma(TF/TI) Trachoma(TF/TI)Active trichiasis Sacarring Opacity
Trachoma
Thatta 62 (1.77) 0 9(0.13) 15 (0.21%) 0
Tharparkar 19 (0.83%) 0 10(0.14%) 18(0.26%) 1 (0.01%)
Shadadkot 346(9.88%) 0 1 (0.01%) 109(1.56%) 3(0.04%)

GilgitBaltistan
CHILDREN ADULTS
Active Active Trachomatous trichiasi Tr. Corneal Opacity
Skardu 51(1.45%) 0 65(0.93%) 32(0.46%) 10(0.24%)
Khyber Pakhtunkhwa
CHILDREN ADULTS
Active Active Trachomatous trichiasis Tr. Corneal Opacity

DI KHAN 12(0.34%) 0 6 (0.09%) 0 2(0.03%)
Chitral 443(12.65%) 0 79(1.13%) 35 ( 0.5%) 0
Batagram 97(2.77%) 0 3(0.04%) 4(0.06%) 0
6.1.2 Key finding of Phase 1

1. Chitral and shadadkot are on high priority whileBatagram,Skardu,
tharparkarThatta, pishin, hafizabad and Narowal are on medium priority for for
Antibiotic distribution.
2. Chitral, Skardu. DG khan and narowal are on high priority for Trichiasis surgery.
6.1.3Phase 2
( Results of 10 districts out of 16 districts)
PUNJAB
Children ADULTS
District Active Trachoma ( TF/TI) Active Trachoma ( TF/TI) TT
Jhang 3 (0.10%) 24(0.39%) 9(0.1%)
kasur 7(0.1%) 4(0.04%) 0
jhelum 99(2.8%) 9(0.1%) 0
Okara 2(0.10%) 45(0.6%) 8(0.1%)
Sialkot 9(0.3%) 10(0.1%) 1(0.1%)

SINDH
Children ADULTS
District Active Trachoma ( TF/TI) Active Trachoma ( TT
TF/TI)
khairpur 5(0.1%) 18(0.2%) 3(0.1%)
Jacobabad 55 ( 1.7%) 58(0.8%) 5(0.1%)
N.feroz 5 (0.10%) 33(0.5%) 0
Dadu
Khyber Pakhtunkhwa
Children ADULTS
District Active Trachoma Active Trachoma TT
Swabi 7(0.3%) 4(0.04%) 1(0.01%)
Baluchistan
Children ADULTS
District Active Trachoma Active Trachoma TT
Lasbela 7(0.3%) 19(0.3%) 0
6.1.4 Key Findings

1. Jhelum and Jacobabad were on medium priority for antibiotic distribution amongst
children for active trachoma.
2. Trichiasis was not a priority an any of these districts.
6.2 Results from the current Phase - Punjab
6.2.1 District Mianwali

The recorded response rate for adults in districtMianwali was 98.6% while in children it
was 94.8%. Amongst those examined 55.80 adults were males while 56.8% were male
children.
Total adults ( total Eligible 7000) 6902 98.60%

Males 3851 55.80%
Females 3051 44.20%
Total Children( total Eligible 3500) 3320 94.86%

Males 1886 56.81%
Females 1434 43.19%

Status of Trachoma
The estimated prevalence of Active Trachoma (TF and TI ) amongst adults was 0.09%.
females had a slightly higher prevalence then males.
The prevalence of Trachomatous trichiasis 0.03%, Trachomatous trichiasis was also 0.07%
and trachomatous scar was 0.07%. There was no significant effect of gender on these
prevalences.
Trachoma Status (Adults 15+ yrs) Males Females Total

Active Trachoma .06% (2) .10% (4) 0.09%(6)
TT 0.% (0) 0.05%(2) 0.03% (2)
TS 0.02% (1) 0.13% (4) 0.07% (5)
Active Trachoma In Children ( 1-9 yrs) 0.13% (1) 0%(0) 0.06% ( 1)
Risk Factors
67% of all the houses had fly breeding sites either inside or near by the house. 0.20% of all
houses had were exposed to fly breeding site and had at least one trachomatous case in
them.
38.16 did not had latrines inside the house. 0.13% had laterines outside the house and had
at least one trachomatous case in them.
Total No of HH 1525 100.00%
Total no affected HH 5 0.33%
Affect HH lat outside 2 0.13%
Un Affect HH lat outside 580 38.03%
Affected fly breeding sites 3 0.20%
un affected fly breeding sites 1012 66.36%
Personal Hygiene
41% of all children between ages 1 years to 09 years, had unclean faces. 0.03% had unclean
face and also had active trachoma.
Affected facial un cleanliness 1 0.03%

Total facial un cleanliness 1430 40.8%
Water Supply ( Total House holds 1525)

52% of houses had their water supply through piped water, 16% were using canal water,
14.4% had access to tube wells water, 10.2% had their own hand pumps inside their houses
and 6.5% were using pons’s water.

Source of water No of houses %
Piped water 800 52.46
Hand pump 156 10.23
Tube well 220 14.43
Pond 100 6.56
River 0.00
Canals 249 16.33
6.2.2 District Bhakkar

6938 adults subjects were examine yielding an excellent response rate of 99.11%. an equally
good response, 98%, was seen amongst children as well.
51.7% of adults while 53.5% of all examined children were males.

males 3589 51.73%
females 3349 48.27%

males 1838 53.59%
females 1592 46.41%
Status of Trachoma
The overall prevalence of active trachoma amongst adults was 0.9%., Trachomatous
trichiasis was 0.03% and trachomatous scar was 0.07%. None of the children had Active
trachoma in this sample.

Active Trachoma .08% (3) 0.0% (0) 0.04%(3)
TT 0.02% (1) 0.02%(1) 0.03% (2)
TS 0.02% (0) 0.13% (4) 0.07% (4)
Active Trachoma In Children ( 1-9 yrs) 0.0% (0) 0.0%(0) 0.0% ( 0)

Risk Factors
8.2% of all houses were exposed to fly breeding sites, 0.225 of houses had trachomatous
case and were exposed to fly breeding sites. 59.^5 of all the houses did not had latrine inside
their houses.

Un affected fly breeding sites 109 8.07%
Personal Hygiene
Overall children had good personal hygiene and only 3.1% children had unclean faces.
Affectd facial cleanliness 0 0.00%

Un affected facial cleanliness 109 3.18%
Water Supply (total no of households – 1350)
42.5% of all houses had hand pump within their houses,33.2% had to bring their water from
canals, 12.5% had access to tube well’s water while only 11% had access to piped water.

Handpump 575 42.59
Tube well 170 12.59
Pond 6 0.44
River 0.00
Canals 449 33.26
6.2.3 Bahawalpur
Response rate for both adults and children was just above 97%. 55% of adults while 59% of
the children were males.

males 3805 55.62%

females 3036 44.38%

Males 2012 59.19%
Females 1387 40.81%
Status of Trachoma
The prevalence of Active trachoma amongst adults was 0.04%, TT was 0.01%, TS was
0.07%.
No active trachoma was noticed in amongst children age 1 – 9 years old.
Active Trachoma 0% (0) 0.10% (3) 0.04%(3)
TT 0.% (0) 0.03%(1) 0.01% (1)
TS 0.02%(1) 0.13% (4) 0.07% (5)
Active Trachoma In Children ( 1-9 yrs) 0% (0) 0%(0) 0% ( 0)
Risk Factors
64% of the houses were exposed to fly breeding sites, only 0.02% of houses had trachoma
with exposure to fly breeding sites.
40% of the total houses did not had latrine facilities at their homes, none of these had any
trachoma cases.

Affected HH lat outside 0 0.00%
Personal Hygiene
88% of all children had uncleaned faces and non of them had active trachoma,
Affected facial cleanliness 0 0.00%
Water Supply (no of households 1249)

63% of the total house holds did not had water supply inside their houses but had access to
tube well water. 15% of the total house hold are using River water,12% had hand pumps
within their houses and only 9.6% had the facility of piped water.

Hand pump 150 12.01
Tube well 789 63.17
Pond 0.00
River 190 15.21
Canals 0.00
6.3. Sindh
6.3.1 District Sanghar

6945 adults and 3370 children were examine yielding response rates of 99.2% and 96.2%
respectively. 51.26% amongst adults and 54% amongst children were males.

males 3560 51.26%
females 3385 48.74%

males 1831 54.33%
females 1539 45.67 %
Status of Trachoma
The prevalence of Active trachoma amongst adults was 0.09% while no cases of trachoma
were found in the children.
The prevalence of TT amongst adults was 0.01%.

Active Trachoma 0.06% (2) 0.10% (4) 0.09%(6)
TT 0.% (0) 0.02%(1) 0.01% (1)
TS 0% (0) 0% (0) 0% (0)
Active Trachoma In Children ( 1-9 yrs) 0% (0) 0% (0) 0% (0)

Risk Factors
635 of the total house were exposed to fly breeding sites, only 0.36 had trachoma cases in
them.
36% of the houses did not had latrines inside their house and also did not had any trachoma
cases.
Personal Hygiene
Only 20% of the children had uncleaned faces and were not affected by trachoma.
Un affected facial cleanliness 650 19.29 %
Water supply
47% of the total house holds had the facility of piped water, 20% had access to Tube well
water, 1% had hand pumps inside their houses and the rest were using either pond water or
canal water.

Handpump 145 17.32
Tube well 170 20.31
Pond 67 8.00
River 0.00
Canals 55 6.57
6.3.2 District Badin

6530 adults and 3470 children were examined with response rates of 93.4 and 99%
respectively.
The proportion of males in both adults and children was similar i.e 53%.
Total adults 6530 93.29

males 3475 53.26
females 3055 46.74

total Children 3470 99.10
males 1831 53.00
females 1539 47.00
Status of Trachoma
The prevalence of Active trachoma was 0.02% amongst adults. No cases of TT or TS were
found amongst adults.
No cases Active trachoma were found in children.

Active Trachoma 0.% (0) .03% (1) 0.02%(1)
TT 0.% (0) 0.% (0) 0.% (0)
TS 0% (0) 0% (0) 0% (0)
Active Trachoma In Children ( 1-9 yrs) 0% (0) 0% (0) 0% (0)
Risk Factors
24% of all houses were exposed to fly breeding sites only 1 house (o.48%) had a trachoma
case in it. 36% of all houses did not had latrine facilities inside houses and none of them had
any trachoma case.
Total No of HH 968 100.00

Total no affected HH 1 0.48
Affect HH lat outside 0 0.00
Un Affect HH lat outside 301 35.96
Affected fly breeding sites 1 0.48
Personal Hygiene
16% of all children had uncleaned faces and none of them had trachoma.
Affected facial cleanliness 0 0.00
Un affected facial cleanliness 569 16.39

Water Supply ( total Households 968)
41.79% houses had access to piped water. 18% had access to open tube wells, 15% had
hand pumps at their homes and another 6% take their water from stagnant ponds.

Hand pump 145 15.32
Tube well 170 18.31
Pond 67 1.00
River 0.00
Canals 55 6.00
6.4 Baluchistan
6.4.1 Gawadar
6790 adults and 3433 children were examined with response rates of 97% and 98%
respectively. 57% of the total examined and 54% of the total examined children were males.

Males 3890 57.29%
Females 2900 42.71%

Males 1864 54.30%
Females 1569 45.70%
Status of Trachoma
The prevalence of Active trachoma was o.o6% amongst adults and 0.04% amongst children.
No Trachomatous trichiasis or Trachomatous scarring was observed in adults.
Active Trachoma 0.03% (2) 0.07% (2) 0.06%(4)
TT 0.% (0) 0.% (0) 0.% (0)
TS 0.% (0) 0.% (0) 0.% (0)
Active Trachoma In Children ( 1-9 yrs) 0.05% (1) 0.% (0) 0.04% ( 1)
Risk Factors

50% of the houses were exposed to fly breeding sites and 68% did not had latrine facilities at
home. A minor portion of these houses had trachomatous subjects within them
Personal Hygiene
Almost 12% of all children had unclean faces, only 0.04% had unclean face with trachoma.
Affected and unclean face 1 0.04%
un affected with unclean 309 11.74%
Water supply
41% people had access to piped water while 29% had the facility of hand pumps within their
houses. Another 20% households had access to tube well water.

Handpump 245 29.27
Tube well 167 19.95
Pond 0.00
River 0.00
Canals 55 6.57
6.5Gilgit Baltistan
6.5.1 District Astore

6887 adults and 3302 children were examined with response rates of 98 and 94%.
The proportion males 52.5% was equal in both adults and children.
Total adults ( total eligible 7000) 6887 98.40%

males 3618 52.53%
females 3269 47.47%
Total Children( total eligible 3500) 3302 94.34%
males 1728 52.33%
females 1574 47.67%

Status of Trachoma
Active Trachoma was present in 0.19% of all adults and 0.79% of all children. 0.17% adults
had trachomatous trichiasis while trachomatous scarring was present in 0.2% adults.

Active Trachoma 0.06% (2) 0.34% (11) 0.19%(13)
TT 0.22% (4) 0.31%(8) 0.17% (12)
TS 0.14% (5) 0.28% (9) 0.20% (14)
Active Trachoma In Children ( 1-9 yrs) 0.58% (10) 1.02%(16) 0.79% ( 26)
Risk Factors
Almost 53% houses were exposed to fly breeding sites. 4.6% had trachoma cases and were
exposed to fly breeding sites. 96% house hold did not had the facility of latrine inside their
homes while only 1% of home did not had latrine and had trachoma cases within them.

Personal Hygiene
21% of all children had unclean faces while only 0.7% had trachoma with unclean faces.
Water Supply ( total no of house holds 1348)

62% of house holds had their supply from the rivers i.e. they had directed small stream from
the river to a reservoir in their homes. 33% use water from stagnant ponds, developed from
melting glaciers. A minor portion of house hold had the luxury of piped water.

Piped water 50 3.71

Hand pump 0.00
Tube well 0.00
Pond 450 33.38
River 848 62.91
Canals 0.00
7.Conclusions
1. The study yielded an excellent response rate between 95 and 99%. Response rate was higher
for males as compared to females
2. The prevalence of Active trachoma was very low in all districts. Astore had medium priority
for Antibiotic distribution.
3. Trachomatous trichiasis was also very low.
4. Clean water supply was a major problem with in almost all districts. Less then 50% of the
population had an access to piped water.
5. Facial cleanliness though not a major issue in relation to trachoma, still a handsome amount
of children had unclean faces.
8. Recommendations
1. Antibiotic distribution in target groups of population in district. Astore is recommended.
2. Mothers and children need to be educated in the importance of personal hygiene and
prevention of diseases.
3. Intersectoral linkages need to be developed to address the issue of water and sanitation.
9. References
1
Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP (2008) Globa magnitude of visual impairment caused by
uncorrected refractive errors in 2004. Bull World Health Organ 86: 63–70.
2
Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, et al. (2004) Global data on visual
impairment in the year 2002. Bull World Health Organ 82: 844–851

3
Polack S, Brooker S, Kuper H, Mariotti S, Mabey D, et al. (2005) Mapping the global distribution of
trachoma. Bull World Health Organ 83: 913–919
4
Taylor HR (2008) Trachoma: a blinding scourge from the Bronze Age to the twenty-first century. Melbourne:
Centre for Eye Research Australia.
5
Barenfanger J (1975) Studies on the role of the family unit in the transmission of trachoma. Am J Trop Med
Hyg 24: 509–515
6
Burton MJ, Holland MJ, Faal N, Aryee EA, Alexander ND, et al. (2003) Which members of a community
need antibiotics to control trachoma? Conjunctival Chlamydia trachomatis infection load in Gambian villages.
Invest Ophthalmol Vis Sci 44: 4215–4222
7
El-Asrar AM, Van den Oord JJ, Geboes K, Missotten L, Emarah MH, et al. (1989) Immunopathology of
trachomatous conjunctivitis.Br J Ophthalmol 73: 276–282
8
Burton MJ, Bailey RL, Jeffries D, Mabey DC, Holland MJ (2004) Cytokine and fibrogenic gene expression in
the conjunctivas of subjects from a Gambian community where trachoma is endemic. Infect Immun 72: 7352–
7356
9
Thylefors B, Dawson CR, Jones BR, West SK, Taylor HR (1987) A simple system for the assessment of
trachoma and its complications. Bull World Health Organ 65: 477–483
10
Loomis WP, Starnbach MN (2002) T cell responses to Chlamydia trachomatis. CurrOpinMicrobiol 5: 87–91
11
Rottenberg ME, Gigliotti-Rothfuchs A, Wigzell H (2002) The role of IFN-gamma in the outcome of
chlamydial infection.CurrOpinImmunol 14: 444–451
12
Bailey R, Duong T, Carpenter R, Whittle H, Mabey D (1999) The duration of human ocular Chlamydia
trachomatis infection is age dependent. Epidemiol Infect 123: 479–486.
13
Grassly NC, Ward ME, Ferris S, Mabey DC, Bailey RL (2008) The natural history of trachoma infection
and disease in a Gambian cohort with frequent follow-up.PLoSNegl Trop Dis 2: e341. doi
14
Wang SP, Grayston JT, Alexander ER (1967) Trachoma vaccine studies in monkeys. Am J Ophthalmol 63:
Suppl-30
15
Sowa S, Sowa J, Collier LH, Blyth WA (1969) Trachoma vaccine field trials in The Gambia. J Hyg (Lond)
67: 699–717
16
Hanna L, Jawetz E, Dawson CR, Thygeson P (1982) Long-term clinical, microbiological, and
immunological observations of a volunteer repeatedly infected with Chlamydia trachomatis. J ClinMicrobiol
16: 895–900
17
Dawson CR, Marx R, Daghfous T, Juster R, Schachter J (1990) What clinical signs are critical in evaluating
the intervention in trachoma? In: Bowie WR, editor. Chlamydial Infections. Cambridge: Cambridge
University Press. pp. 271–278
18
West SK, Munoz B, Mkocha H, Hsieh YH, Lynch MC (2001) Progression of active trachoma to scarring in
a cohort of Tanzanian children. Ophthalmic Epidemiol 8: 137–144
19
Burton MJ, Kinteh F, Jallow O, Sillah A, Bah M, et al. (2005) A randomised controlled trial of azithromycin
following surgery for trachomatoustrichiasis in the Gambia. Br J Ophthalmol 89: 1282–1288
20
Courtright P, Sheppard J, Schachter J, Said ME, Dawson CR (1989) Trachoma and blindness in the
Nile Delta: current patterns and projections for the future in the rural Egyptian population. Br J Ophthalmol
73: 536–540
21
West SK, Munoz B, Turner VM, Mmbaga BB, Taylor HR (1991) The epidemiology of trachoma in central
Tanzania. Int J Epidemiol 20: 1088–1092
22
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trachomatoustrichiasis in children: cross-sectional household surveys in Southern Sudan. Trans R Soc
Trop Med Hyg 103: 305–314
23
Dolin PJ, Faal H, Johnson GJ, Ajewole J, Mohamed AA, et al. (1998) Trachoma in The Gambia. Br J
Ophthalmol 82: 930–933.
24
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components of the SAFE strategy for trachoma control. Trop Med Int Health 5: 515–527
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Trachoma Pakistan

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National Trachoma Survey

Dr. Muhammad Zahid Jadoon

5. Ethical Approval ........................................................................................ 8

6.2 Results from the current Phase - Punjab............................................... 11

6.3. Sindh .................................................................................................... 16

6.4 Baluchistan ............................................................................................ 19

6.5Gilgit Baltistan ........................................................................................ 20

Conclusions & Recommendations

Pathogenesis and Clinical Features

Table 1. The WHO simplified system for the assessment of trachoma 8

National Trachoma Survey 2

National Trachoma Survey 3

Eye Health in Pakistan

National Trachoma Survey

National Trachoma Survey 4

3.2 Sample size

3.3 Sampling Strategies

Selection of Households within villages.

National Trachoma Survey 5

3.6 Teams compositions

3.7 Selection of districts

3.7.1 First Phase (15- Districts)

National Trachoma Survey 6

3.7.2 Second Phase (16 Districts)

The second Phase was sponsored by Sight Savers only.

The Trachoma Survey in additional 16-Districts of Pakistan has been accomplished..

Data was managed and analysed at Pakistan Institute of Community Ophthalmology

3.7.3 Third Phase (7 Districts)

The third phase is sponsored by Fred Hollows Foundation.

Punjab: MianwaliBhakkar and Bahawalpur

National Trachoma Survey 7

3.10 Quality assurance

National Trachoma Survey 8

6.1.1 Phase1 (15 Villages were surveyed)

National Trachoma Survey 9

Active Active Trachomatous trichiasis Tr. Corneal Opacity

6.1.2 Key finding of Phase 1

National Trachoma Survey 10

6.1.4 Key Findings

6.2 Results from the current Phase - Punjab

6.2.1 District Mianwali

Total adults ( total Eligible 7000) 6902 98.60%

Total Children( total Eligible 3500) 3320 94.86%

National Trachoma Survey 11

Trachoma Status (Adults 15+ yrs) Males Females Total

Affected facial un cleanliness 1 0.03%

Water Supply ( Total House holds 1525)

National Trachoma Survey 12

6.2.2 District Bhakkar

51.7% of adults while 53.5% of all examined children were males.

Total adults ( total Eligible 7000) 6938 99.11%

Total Children( total Eligible 3500) 3430 98.00%

Trachoma Status (Adults 15+ yrs) Males Females Total

National Trachoma Survey 13

Total No of HH 1350 100.00%

Affectd facial cleanliness 0 0.00%

Water Supply (total no of households – 1350)

Source of water No of houses %

National Trachoma Survey 14

males 3805 55.62%

Total Children( total Eligible 3500) 3399 97.11%

Total No of HH 1249 100.00%

Affected facial cleanliness 0 0.00%