Trachoma surveillance annual report, 2008

The National Trachoma Surveillance and Reporting Unit (NTSRU) was established in November 2006 to improve the quality and consistency of data collection and reporting of active trachoma in Australia. This page contains links to trachoma surveillance annual reports for 2008.

Page last updated: 07 December 2009

A report by the National Trachoma Surveillance and Reporting Unit

Betty Tellis, Kathy Fotis, Jill E Keeffe, Hugh R Taylor

Abstract

The National Trachoma Surveillance and Reporting Unit has reported data for trachoma endemic regions and communities in the Northern Territory, South Australia and Western Australia for 2006 to 2008. Aboriginal children aged 1 to 9 years were examined using the World Health Organization grading criteria. Screening in the Northern Territory was conducted by the primary health care staff from the Healthy School Age Kids program, the Australian Government Emergency Intervention and Aboriginal Community Controlled Health Services. Forty-three of 92 communities in 6 regions were screened and reported data (2,462 children). In South Australia, the Eye Health and Chronic Disease Specialist Support Program and a team of eye specialists visited 11 of 72 communities in regions serviced by 6 Aboriginal Community Controlled Health Services (365 children). In Western Australia, population health unit and primary health care staff screened and reported data for 67 of 123 communities in 4 regions (1,823 children). Prevalence rates of active trachoma varied between the regions with reported prevalence ranging from 4%–67% in the Northern Territory, 0%–13% in South Australia and 8%–25% in Western Australia. Statistical comparisons must be viewed with caution due to the year-to-year variation in the coverage of children examined and the small numbers. Comparisons of 2006, 2007 and 2008 regional prevalence of active trachoma showed that many communities had no change in prevalence, though there were a few statistically significant increases and decreases (P < 0.05). The number of communities screened and the number of children examined has improved but still remains low for some regions. The implementation of the World Health Organization Surgery (for trichiasis), Antibiotics (with azithromycin), Facial cleanliness and Environmental improvement (SAFE) strategy has been variable. Few data continue to be reported for the surgery and environmental improvement components. In general, the availability of the community programs for surgery, antibiotic treatment, and facial cleanliness has improved. Reporting of antibiotic treatment has improved from 2006 to 2008. No significant changes were noted in bacterial resistance reported by pathology services from 2007 to 2008; these rates are comparable to national data collected by the Advisory Group on Antibiotic Resistance in 2005. Commun Dis Intell 2009;33(3):275–290.

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Introduction

This is the third report of the National Trachoma Surveillance and Reporting Unit (NTSRU). This report aims to compare 2008 data with results from the screening in 2006 and 2007 conducted in the Northern Territory, South Australia and Western Australia in regions with endemic trachoma.1,2 It comments on jurisdictions' implementation of the Communicable Diseases Network Australia (CDNA) trachoma guidelines 'minimum best-practice approach', and makes recommendations regarding future reporting and management.3

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Methods

Presented below is a summary of the data collection methods used by the jurisdictions and the data analysis and reporting methods used by the NTSRU. A detailed description of the 2008 report is included in the full 2008 report.4

Screening and data collection

Key representatives from each jurisdiction categorised communities that were 'At Risk' or 'Not At Risk' for trachoma, and further categorised each group into screened or not screened. Communities considered At Risk were determined using historical reports of trachoma in their regions. In most cases this did not include the large urban regions. For many communities in South Australia there was no information on prior screening for trachoma; these communities have been reported as At Risk and should have been screened.

According to the CDNA guidelines, screening should be conducted annually in Communities At Risk until prevalence of active trachoma is less than 5% for 5 consecutive years. The World Health Organization (WHO) has set the criteria for the elimination of blinding endemic trachoma in a community as being a prevalence of active trachoma greater than 5% in children aged 1 to 9 years or a prevalence of operable trichiasis of less than 0.1% in the population.

The WHO simplified trachoma grading system was used to report results of screening.5 Active trachoma includes WHO grades trachomatous inflammation follicular (TF) and/or trachomatous inflammation intense (TI).

In brief, data were reported for prevalence of active trachoma, antibiotic treatment of children, their household contacts and community members, facial cleanliness, trachomatous trichiasis (TT) and surgery for trichiasis. The implementation of the Surgery, Antibiotics, Facial cleanliness and Environmental improvements (SAFE) components of the SAFE trachoma control strategy were also reported. This report focuses on the data for Aboriginal children aged 1 to 9 years and Aboriginal adults aged 30 years or more—unless otherwise specified—to comply with CDNA guidelines.

The NTSRU monitored antibiotic resistance in Aboriginal communities for 2 years (2007 and 2008). Three pathology services collected and reported data: the Institute of Medical Veterinary Science (IMVS), the Northern Territory Government Pathology Service (NTGPS) and the Western Diagnostics Pathology Service (WDPS). The participating laboratories and health services reported azithromycin resistance (defined as both intermediate and high level resistance) for any invasive and non-invasive isolates of Streptococcus pneumoniae specimens collected from Aboriginal people in trachoma endemic regions. Specimens were collected over a 6 month period in 2008 (1 July to 30 December) because too few results were reported within the 3 month collection period in 2007. Information on indigenous status was only reported from the NTGPS. IMVS and WDPS provided data for specimens from those regions or health services that predominately service Aboriginal people.

Northern Territory

Screening for trachoma was conducted between February and November 2008 in 6 regions. The Healthy School Age Kids (HSAK) program conducted most of the screening in the Top End and in Central Australia with collaboration with primary health care staff from the Aboriginal Community Controlled Health Services (ACCHS). In 2008 the HSAK program was fully implemented in Central Australia.

Screening was conducted in an Alice Springs town camp for the first time by the trachoma coordinator in conjunction with the Australian Government Emergency Intervention (AGEI) at the Central Australian Aboriginal Congress. Previously, Alice Springs town camps had not been screened because they were not regarded as At Risk for trachoma and because the HSAK program is responsible for remote areas.

In 2007, the AGEI conducted Child Health Checks throughout the Northern Territory. The AGEI clinical advisory panel decided that trachoma screening was only to be conducted by members of the intervention teams who had appropriate skills and training to do so. During Phase 2 of the AGEI in 2008, some children in the Northern Territory were examined for trachoma during the Child Health Check. The screening reported was not regarded as reliable or consistent by the Northern Territory authorities so has not been included in this report. The communities that were visited by the AGEI (n=14) were not revisited by the HSAK program and this contributed to the smaller number of communities reporting active trachoma data for 2008.

Ophthalmologists examined Aboriginal adults for trichiasis when they conducted outreach visits in the regions.

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South Australia

Screening for trachoma was conducted between April and December 2008 in regions serviced by 6 ACCHSs. The Ceduna/Koonibba region includes communities in the Eyre school district (located south-east of the Ceduna/Koonibba Health Service). This incorporates communities serviced by the Port Lincoln ACCHS region where screening has not been conducted. The Pika Wiya region includes communities from within the Flinders school district, and 2 communities from the Northern Country school district, which were reassigned by the Eye Health and Chronic Disease Specialist Support Program (EH&CDSSP) coordinator. For this reason the Australian Bureau of Statistics Census data for the Aboriginal population in the Ceduna/Koonibba and Pika Wiya regions appear larger than what would be expected for some of these regions as serviced by the ACCHS.

In 2006 communities in regions serviced by Oak Valley ACCHS were reported with communities from the Ptyalin ACCHS; these data have been combined together in Table 1 so comparisons can be made for each year between 2006 and 2008.

Table 1: Community coverage, screening coverage and active trachoma prevalence of Aboriginal children aged 1 to 9 years, 2006 to 2008, by state or territory, region and Aboriginal Community Controlled Health Service

State or territory and region
Number of Communities At Risk Community coverage
Number of communities screened
(% of Communities At Risk)
Screening coverage
Number of children examined
(% of children in Communities At Risk)
Prevalence of active trachoma
Children 1 to 9 years
(% prevalence)
2008 2006 2007 2008 2006 2007 2008 2006 2007 2008
n n % n % n % n % n % n % n % n % n %
Northern Territory
Alice Springs
1
1
100
45
22
18
40
Alice Springs Remote
30
25
83
19
63
18
60
530
35
231
15
459
29
94
18
46
20
157
34*
Barkly
8
6
67
6
67
2
25
105
20
68
13
87
26
22
21
18
26
58
67*
Darwin Rural
16
15
94
12
75
11
69
522
27
377
19
907
45
84
16
25
7
183
20*
East Arnhem
12
12
100
12
100
4
33
879
78
465
41
232
20
22
3
23
5
10
4
Katherine
20
11
52
11
52
7
35
218
12
562
31
732
50
65
30
104
19
287
39*
Total
87
69
78
60
67
43
49
2,254
33
1,703
24
2,462
36
287
13
216
13
713
29*
South Australia
Ceduna/Koonibba
21
1
5
1
5
1
5
18
1
16
1
121
6
1
6
1
6
0
0
Nganampa
10
8
80
4
40
6
60
27
8
76
23
167
50
5
19
10
13
4
2*
Oak Valley
2
2
100
2
100
2
100
28
108
34
131
25
93
7
25
7
21
2
8
Pika Wiya
33
5
15
1
3
51
1
37
1
6
12
0
0*
Umoona Tjutagku
6
1
17
1
17
1
17
6
7
2
2
15
17
1
17
0
0
0
0
Total
72
17
24
8
11
11
15
130
1
128
1
365
4
20
15
18
14
6
2*
Western Australia
Goldfields
20
6
30
10
50
13
65
231
24
227
23
238
23
43
19
8
4
18
8*
Kimberley
34
28
82
25
83
32
94
1,048
51
1,006
58
1,169
55
192
18
164
16
175
15
Midwest
6
6
100
5
83
6
100
167
90
127
68
122
64
32
19
28
22
12
10*
Pilbara§
16
9
56
14
88
16
100
273
36
306
40
294
37
146
53
50
16
73
25*
Total
76
49
64
54
75
67
88
1,719
43
1,666
45
1,823
44
413
24
250
15
278
15*
Australia
235
135
57
122
52
121
51
4,103
21
3,497
18
4,650
23
720
18
484
14
997
21*

– Data not reported.

* P < 0.05 = statistical significant change found between 2006 and 2008 using chi-square test.

† Barkly had 9 Communities At Risk of trachoma in 2006 and 2007; Katherine had 21 Communities At Risk in 2006 and 2007; and the Kimberley had 30 Communities At Risk in 2007.

‡ Communities in regions serviced by the Oak Valley Aboriginal Community Controlled Health Services (ACCHS) were reported with communities from the Tullawon ACCHS.

§ Change in grading from 2007.

Source: Data were collected by the Healthy School Age Kids program in Northern Territory, the Eye Health and Chronic Disease Specialist Support Program in South Australia and population health units in Western Australia.

A widespread screening program was not implemented as the EH&CDSSP only visits selected communities serviced by some ACCHS. The project coordinator of the EH&CDSSP assisted a screening team of ophthalmologists and optometrists in recording information on active trachoma. Some communities were visited twice over a 1 year period, however only 1 round of data was reported. Aboriginal children who were identified for screening were seen in schools and others brought to the clinics by family members, Aboriginal health workers or clinic staff.

Data from the Pika Wiya region were collected by the mainstream Health Service and forwarded to the EH&CDSSP coordinator to be included in this report.

The screening team of eye specialists also visited ACCHS clinics twice in the year to examine adults for trichiasis.

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Western Australia

Screening for trachoma was conducted between August and September 2008 in 4 regions. Population Health Units collected data in partnership with primary health care staff from state government ACCHS. In most regions letters were sent to parents in order to gain permission for the screening of their children.

Adults were examined for trichiasis as part of an annual influenza vaccination program.

Data analysis and reporting

Comparisons between jurisdictions need to be interpreted with caution because of the variation in methods, data collection and reporting.

In 2008, a community was defined as a group of people where there is a school; larger communities where two or more schools are located were counted as a single community instead of reporting data for each school separately. Community coverage was calculated using the number of communities that were screened as a proportion of those that were identified by each jurisdiction as At Risk. Communities that were reported as Not At Risk and were not screened are not included.

The 2006 Australian Bureau of Statistics (ABS) census data of the number of Aboriginal people resident in a region were used to calculate 2008 high and low series population projections.6,7 Screening coverage was calculated using the number of children who were examined for trachoma in 2008 as a proportion of those who were estimated by the ABS to be resident in Communities At Risk.

The prevalence of active trachoma in Aboriginal children aged 1–9 years was calculated using the number of children examined as the denominator and 95% confidence intervals were calculated.

CDNA guidelines recommend providing azithromycin treatment to affected children, their households and community members. In some communities the treatment strategy was not reported, although some treatment was distributed. In other communities, treatment was reported to have been distributed where active trachoma was found in children aged 10–14 years without being detected in children aged 1–9 years. Where the data indicated that treatment was only given to affected children, without providing household or community treatment, these communities were regarded as not following the CDNA guidelines.

Comparisons must be viewed with caution due to the year-to-year variation in methods, data collection and reporting, and the small numbers of children examined. For comparisons to be made eligible communities had to report comparable data for at least 2 years. Chi-square tests were used to detect significant differences (P < 0.05) in the prevalence of active trachoma for communities that examined 10 or more children in two or more years. Where numbers were less than five in any cell, a Fisher's exact test was used. Analysis could not be conducted on 2006 data for 2 regions in Western Australia: the Kimberley region (where the number of children examined from each community was not reported) and the Pilbara region (where follicular trachoma was not graded according to the WHO grading system). In 2008, comparisons of prevalence of active trachoma were not possible for 4 of the 7 communities in the Katherine region of the Northern Territory where data were provided for children aged 0 to 15 years.

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Results

National overview

A total of 16 regions in the Northern Territory, South Australia and Western Australia conducted screening. Other jurisdictions were not included in this project (Map).

Map: Prevalence of active trachoma in Australia, 2008, by region

Map:  Prevalence of active trachoma in Australia, 2008, by region

* No active trachoma was found, however few children were examined in this area (n=9).

Data were reported for 121 of the 235 Communities At Risk (51%) in 2008 (Table 2). The overall prevalence of active trachoma in Aboriginal children aged 1 to 9 years for whom data were reported was 21% (Table 1). A total of 82 communities (68%) had a prevalence of active trachoma ≥ 5% (Table 3), and this occurred in 10 of the 15 regions (67%) (Table 1).

Table 2: Number of communities screened for trachoma by trachoma risk, state and territory, 2008

Communities
Number and percentage of communities Total
Northern Territory South Australia Western Australia
n % n % n % n %
Not At Risk
Screened
0
0
0
0
Not screened
5
100
0
47
100
52
100
Total Not At Risk
5
0
47
52
At Risk
Screened with no trachoma found
4
5
7
10
16
21
27
11
Screened with trachoma found
39
45
4
6
51
67
94
40
Reported screened but no data received
19
22
0
2
3
21
9
Not screened
25
29
61
85
7
9
93
40
Total At Risk
87
72
76
235
Total communities
92
72
123

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Table 3: Community prevalence of active trachoma in Aboriginal children aged 1 to 9 years, 2006 to 2008, by state or territory

Community prevalence
Number and percentage of communities where trachoma data were reported Total
Northern Territory South Australia Western Australia
n % n % n % n %
2006 data
0
30
42
0
5
9
35
26
1 to <5
7
10
0
3
6
10
5 to <10
7
10
2
25
8
15
17
13
10 to <20
6
8
3
38
6
11
15
11
20 to <50
12
17
3
38
19
36
34
26
≥ 50
10
14
0
12
23
22
17
Total
72
100
8
100
53
100
133
100 
2007 data
0
29
48
2
25
20
36
51
41
1 to <5
7
12
0
0
7
6
5 to <10
4
7
2
25
5
9
11
9
10 to <20
8
13
2
 
25
12
22
22
18
20 to <50
11
18
2
25
16
29
29
24
≥ 50
1
2
0
2
4
3
2
Total
60
100
8
 
100
55
100
123
100
2008 data
0
4
9
7
64
16
24
27
22
1 to <5
4
9
1
9
7
10
12
10
5 to <10
4
9
2
18
8
12
14
12
10 to <20
6
14
1
9
7
10
14
12
20 to <50
16
37
0
21
31
37
31
≥ 50
9
21
0
8
12
17
14
Total
43
100
11
 
100
67
100
121
100

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Of the communities where data were reported for the screening of active trachoma, facial cleanliness data were reported by 93 (76%) of 123 communities in 2007 and 108 (89%) of 121 in 2008. Many communities have tried to break the cycle of re-infection by promoting facial cleanliness through the use of programs (70%) and resources (49%) (Table 4).

Table 4: Implementation of trachoma control activities (SAFE strategy), 2008, by state or territory

SAFE trachoma control activities
Number and percentage of communities where trachoma control activities were reported Total
Northern Territory South Australia Western Australia
n % n % n % n %
Surgery referral process for trichiasis available
39
91
4
36
26
39
69
57
Antibiotics distributed
35
81
5
45
50
75
90
74
Facial cleanliness resources used
27
63
1
9
31
46
59
49
Facial cleanliness programs implemented
32
74
0
53
79
85
70
Good environmental condition
2
5
0
9
13
11
9
Total number of communities where trachoma screening data were reported
43
11
67
121

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Treatment was reported to have been distributed in 90 (92%) of the 98 communities in which treatment for trachoma was indicated (Table 5), including 4 communities where active trachoma was found in children aged 10 to 14 years. Overall, 76 (78%) communities were treated according to CDNA guidelines, this included children found to have active trachoma, their household contacts and community members.

Table 5: Reported treatment for trachoma, 2008, by state or territory

Communities
Northern Territory South Australia Western Australia Total
n % n % n % n %
Treated in compliance with CDNA guidelines*
Community-based
9
26
0
20
49
29
38
Household-based
19
54
0
21
51
40
53
Strategy not reported
7
20
0
0
7
9
Total treated
35
0
41
76
Not treated in compliance with CDNA guidelines
Children only
0
5
100
9
82
14
64
No treatment reported
6
100
0
2
18
8
36
Total not following CDNA
6
5
11
22
Total communities
41
5
52
98

* Includes 2 communities in the Northern Territory, 1 in South Australia and 1 in Western Australia, where active trachoma was found in children aged 10 to 14 years without being detected in children aged 1 to 9 years.

† Communities carried out treatment but the strategy was not reported.

The Communicable Diseases Network Australia (CDNA) guidelines recommend that treatment of children and household or community contacts aged over 6 months be completed in as short a time frame as possible where population mobility is high.

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Community coverage varied between each state and territory with higher coverage in Western Australia and consistently low coverage in South Australia (Table 1). Comparisons must be viewed with caution due to the year-to-year variation in methods, data collection and reporting, and the small numbers of children examined. A comparison between 2006 and 2008 regional prevalence data found there was no change in prevalence in 6 regions, a statistically significant increase (P < 0.05) in prevalence was found in 4 regions, and a decrease (P < 0.05) in 5 regions (Table 1). Of the 77 communities where comparable data were provided, 53 (69%) communities had no significant change (Table 6).

Table 6: Changes in the prevalence of active trachoma in Aboriginal children aged 1 to 9 years in communities where ≥10 children were examined, 2006 to 2008, by state or territory

Change in prevalence of active trachoma 2006–2008
State or territory Total
Northern Territory South Australia Western Australia
n % n % n % n %
Significant decrease*
2
6
0
8
21
10
13
No change
21
64
6
100
26
68
53
69
Significant increase*
10
30
0
4
11
14
18
Total communities
33
6
38
77

* Fisher's test used to evaluate change; significant at P < 0.05.

Source: Data were collected by the Healthy School Age Kids program in the Northern Territory, the Eye Health and Chronic Disease Specialist Support Program coordinator and the screening team in South Australia, and population health units in Western Australia.

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Trichiasis screening was carried out only in a small proportion of Communities At Risk (62/235), but the overall prevalence in the adults examined was 4% (52/1,407) (Table 7, 8 and 9). Not all communities where data were reported are implementing the components of the SAFE strategy according to the CDNA guidelines, but antibiotic treatment and facial cleanliness programs are being reported by the majority, 74% (90/121) and 70% (85/121) respectively (Table 4).

Table 7: Trichiasis screening reported for Aboriginal adults aged ≥ 30 years in the Northern Territory, 2008, by region

  Alice Springs Alice Springs Remote Barkly Darwin Rural East Arnhem Katherine Total
Regional population (ABS)
Adults resident:
In region*
1,838
3,521
1,301
3,297
3,309
3,041
16,307
In Communities At Risk*
514
3,010
542
3,173
2,315
2,038
11,592
Trichiasis
Communities from which data were reported/Communities At Risk
0/1
12/30
2/8
0/16
0/12
0/20
14/87
Adults examined
183
23
206
With trichiasis
23
3
26
Prevalence of trichiasis (%)
13
13
13
Trichiasis surgery within 12 months prior to the date of reporting
36
3
7
46

– Data not reported.

* Projected 2008 population data for the whole region based on the Australian Bureau of Statistics (ABS) 1.4% low series population growth rate in the Northern Territory.

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Table 8: Trichiasis screening reported for Aboriginal adults aged ≥30 years in South Australia, 2008, by Aboriginal Community Controlled Health Service

  Ceduna/ Koonibba* Nganampa Oak Valley (Maralinga Tjarutja) Pika Wiya Tullawon Umoona Tjutagku Total
Regional population (ABS)
Adults resident
In region
3,568
673
34
11,772
28
206
16,281
In Communities At Risk
3,568
673
34
11,772
28
206
16,281
Trichiasis
Communities from which data were reported/ Communities At Risk
0/21
6/10
0/1
1/33
0/1
1/6
8/72
Adults examined
221
26
51
298
With trichiasis
1
0
0
1
Prevalence of trichiasis (%)
0.5
0
0
0.3
Trichiasis surgery within 12 months prior to the date of reporting
1
1

– Data not reported.

* Regional population data of Aboriginal adults and the number of Communities At Risk include adults and communities in the Eyre school district in South Australia and incorporates those serviced by the Port Lincoln Aboriginal Community Controlled Health Service region where screening has not been conducted.

† Regional population data of Aboriginal adults, and the number of Communities At Risk, include adults and communities in the Flinders school district in South Australia and two communities from the Northern Country school district which were reassigned by the Eye Health and Chronic Disease Specialist Support Program coordinator.

‡ Projected 2008 population data for the whole region based on the Australian Bureau of Statistics (ABS) 1.9% low series population growth rate in South Australia.

All communities in South Australia were considered At Risk, therefore the number of adults resident in the region and in Communities At Risk is the same.

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Table 9: Trichiasis screening reported for Aboriginal adults aged ≥ 30 years in Western Australia, 2008, by region

  Goldfields Kimberley Midwest Pilbara Total
Regional population (ABS)
Adults resident:
In region*
2,063
3,551
2,185
2,384
10,183
In Communities At Risk*
1,761
3,321
406
1,585
7,073
Trichiasis
Communities from which data were reported/ Communities At Risk
11/20
15/34
5/6
9/16
40/76
Adults examined
67
442
210
184
903
With trichiasis
3
21
1
0
25
Prevalence of trichiasis (%)
4
5
0.5
0
3
Trichiasis surgery within 12 months prior to the date of reporting
2
2

– Data not reported.

* Projected 2008 population data for the whole region based on the Australian Bureau of Statistics (ABS) 1.8% low series population growth rate in Western Australia.

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Northern Territory

Of the 92 communities in 6 regions of the Northern Territory, 87 (95%) communities were categorised as being At Risk for trachoma (Table 2). Included in these communities was a community (town camp) in Alice Springs, previously categorised Not At Risk. After finding a 40% prevalence of active trachoma in children, this community was then re-categorised as At Risk (Table 1). Of the 62 (71%) communities that were screened in 2008, data were reported from 43 (69%) (Table 2). Four (9%) communities had no active trachoma while 35 (81%) had a prevalence of active trachoma of ≥ 5% (Table 3).

Of the 6,747 children aged 1–9 years reported by the ABS to be resident in Communities At Risk (Table 10), 2,462 (36%) were examined for trachoma, and 713 had active trachoma (prevalence = 29%, 95% CI, 27%–31%) (Table 1). Comparisons for prevalence of active trachoma were not possible for four of the 7 communities in the Katherine region, where data were provided for children aged 0 to 15 years instead of 1 to 9 years, and age breakdowns were not provided. Of the 1,493 children examined for facial cleanliness, 1,004 (67%) had clean faces (Table 10).

Table 10: Number of resident Aboriginal children aged 1 to 9 years, and number of communities and children examined for facial cleanliness in the Northern Territory, 2008, by region

  Alice Springs Alice Springs Remote Barkly Darwin Rural East Arnhem Katherine Total
Regional population (ABS)
Children resident:
In region*
954
1,817
661
2,146
1,916
1,991
9,485
In Communities At Risk*
201
1,577
341
2,013
1,155
1,460
6,747
Facial cleanliness
Communities from which data were reported/ Communities At Risk
1/1
18/30
2/8
5/16
2/12
2/20
30/87
Children examined
45
468
87
627
133
133
1,493
Prevalence of clean faces (%)
12
47
48
79
84
89
67

* Projected 2008 population data for the whole region based on the Australian Bureau of Statistics (ABS) 1.4% low series population growth rate in the Northern Territory.

Treatment was reported to have been distributed according to the CDNA guidelines in 35 (85%) of the 41 communities in which treatment for trachoma was indicated (Table 5). This included 2 communities where active trachoma was found in children aged 10 to 14 years.

Comparison of prevalence of active trachoma was made for 33 of 64 communities where data were reported for at least two of the years between 2006 and 2008. No change in prevalence was found in 21 (64%) communities, a statistically significant increase (P < 0.05) was found in 10 (30%) and a decrease (P < 0.05) was found in 2 (6%) (Table 6).

Data on trichiasis were reported for the Alice Springs Remote and Barkly regions only and 26 Aboriginal adults (13%) aged ≥ 30 years were found to have trichiasis (Table 7). Forty-six adults were reported to have undergone surgery for trichiasis within 12 months prior to the date of reporting.

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South Australia

Of the 72 communities in 6 ACCHS of South Australia, all were categorised as being At Risk for trachoma, of which 11 communities (15%) were visited and data reported (Table 2). Seven (64%) communities had no active trachoma while 3 (27%) had a prevalence of active trachoma of ≥ 5% (Table 3).

Of the 9,218 children aged 1–9 years reported by the ABS to be resident in Communities At Risk (Table 11), 365 (4%) were examined for trachoma, and 6 had active trachoma (prevalence = 2%, 95% CI, 1%–4%) (Table 1); 260 (71%) had clean faces (Table 11).

Table 11: Number of resident Aboriginal children aged 1 to 9 years and number of communities and children examined for facial cleanliness in South Australia, 2008, by Aboriginal Community Controlled Health Service

  Ceduna/ Koonibba* Nganampa Oak Valley (Maralinga Tjarutja) Pika Wiya Tullawon Umoona Tjutagku Total
Regional population (ABS)
Children resident:
In region
2,083
334
9
6,687
18
87
9,218
In Communities At Risk
2,083
334
9
6,687
18
87
9,218
Facial cleanliness
Communities from which data were reported/ Communities At Risk
1/21
6/10
1/1
1/33
1/1
1/6
11/72
Children examined
121
167
16
37
9
15
365
Prevalence of clean faces (%)
100
47
0
100
100
100
71

* Regional population data of Aboriginal children and the number of Communities At Risk include children and communities in the Eyre school district in South Australia, and incorporates those serviced by the Port Lincoln Aboriginal Community Controlled Health Service region where screening has not been conducted.

† Regional population data of Aboriginal children and the number of Communities At Risk include children and communities in the Flinders school district in South Australia and 2 communities from the Northern Country school district, which were reassigned by the Eye Health and Chronic Disease Specialist Support Program coordinator.

‡ Projected 2008 population data for the whole region based on the Australian Bureau of Statistics (ABS) 1.9% low series population growth rate in South Australia.

All communities in South Australia were considered At Risk, therefore the number of children resident in the region and in Communities At Risk is the same.

Treatment was reported to have been distributed in all five of the communities in which treatment for trachoma was indicated, including 1 community where active trachoma was found in 1 child aged 10 to 14 years without being detected in children aged 1 to 9 years (Table 5). Treatment was given to 7 children (6 aged 1–9 and another aged 14 years) who were examined and found to have active trachoma. CDNA treatment guidelines were not followed as household treatment was not given irrespective of the presence of trachoma. This was similar to 2006 and 2007.

Comparison of prevalence of active trachoma was made for 6 of 11 communities where data were reported for at least two of the years between 2006 and 2008, however no statistically significant changes were found (Table 6).

Data for trichiasis were reported for three of the 6 ACCHSs only, and 1 (0.3%) adult was found to have trichiasis. One adult was reported to have undergone surgery for trichiasis within 12 months prior to the date of reporting (Table 8).

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Western Australia

Of the 123 communities in 4 regions of Western Australia, 76 (62%) communities were categorised as being At Risk for trachoma, of which 69 (91%) were screened in 2008 (Table 2). Data were reported from 67 (97%) of these communities. Sixteen (24%) communities had no active trachoma while 44 (66%) had a prevalence of active trachoma ≥ 5% (Table 3).

Of the 4,112 children aged 1–9 years reported by the ABS to be resident in Communities At Risk (Table 12), 1,823 (44%) were examined for trachoma, and 278 had active trachoma (prevalence = 15%, 95% CI, 13%–17%) (Table 1). Of the 1,833 children examined for facial cleanliness, 1,433 (78%) had clean faces (Table 12).

Table 12: Number of resident Aboriginal children aged 1 to 9 years, and number of communities and children examined for facial cleanliness in Western Australia, 2008, by region

  Goldfields Kimberley Midwest Pilbara Total
Regional population (ABS)
Children resident:
In region*
1,184
2,875
1,239
1,199
6,497
In Communities At Risk*
1,017
2,116
192
787
4,112
Facial cleanliness
Communities from which data were reported/ Communities At Risk
13/20
32/34
6/6
16/16
67/76
Children examined
235
1,182
122
294
1,833
Prevalence of clean faces (%)
72
81
82
72
78

* Projected 2008 population data for the whole region based on the Australian Bureau of Statistics (ABS) 1.8% low series population growth rate in Western Australia.

Treatment was reported to have been distributed according to the CDNA guidelines in 41 of the 52 communities (79%) in which treatment for trachoma was indicated (Table 5), including one community where active trachoma was found in children aged 10 to 14 years.

Comparisons must be viewed with caution due to the year-to-year variation in methods, data collection and reporting, and the small numbers of children examined. Comparison of prevalence of active trachoma was made for 38 out of 62 communities where data were reported for at least two of the years between 2006 and 2008; 11 between 2006 and 2008, and 27 between 2007 and 2008. No change in prevalence was found in 26 communities (68%), a statistically significant increase (P < 0.05) was found in 4 (11%) and a decrease (P < 0.05) was found in 8 (21%) (Table 6).

Data on trichiasis were reported for all 4 regions, and 25 adults (3%) were found to have trichiasis. Two adults were reported to have undergone surgery for trichiasis within 12 months prior to the date of reporting (Table 9).

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Antibiotic resistance

The reporting of azithromycin antibiotic treatment in trachoma endemic jurisdictions has improved from 2006 to 2008 (Table 13).

Table 13: Percentage of people treated with azithromycin (total treated/total requiring treatment) in jurisdictions where trachoma is regarded as endemic, 2006 to 2008

  2006* 2007 2008
Northern Territory
–/287
328/533
(62%)
3,069/4,860
(63%)
South Australia
19/20
(95%)
18/18
(100%)
7/7
(100%)
Western Australia§
396/471
(84%)
1,675/2,084
(80%)
2,917/3,013
(97%)
Total
415/778
(53%)
2,235/2,635
(85%)
5,993/7,880
(76%)

– Data not reported.

* No jurisdiction reported the number of household or community contacts treated.

† An additional 871 people were treated in 4 communities in the Katherine region (Northern Territory), they have not been included in the total because the number of people requiring treatment was not provided.

‡ Number of children found to have active trachoma at the first screening have been reported, no household or community contacts were treated irrespective of the presence of trachoma.

§ Treatment data were reported for only two out of the 4 regions in 2006.

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Overall, 53 of the 261 S. pneumoniae isolates (20.3%, 95% CI, 16%–26%) were reported to be resistant or have intermediate resistance to azithromycin (Table 14).

Table 14: Azithromycin resistance and susceptibility to Streptococcus pneumoniae isolates collected from Aboriginal people, 2008, by pathology service and region

Pathology service/ region
Number and percentage of isolates Total %
Resistant % Intermediate % Susceptible %
Institute of Medical Veterinary Science
Goldfields
0
0
1
100
1
100
Nganampa
3
27
0
8
73
11
100
Pika Wiya
0
0
2
100
2
100
Subtotal
3
21
0
11
79
14
100
Northern Territory Government Pathology Service
Alice Springs
11
38
1
3
17
59
29
100
Alice Springs Remote
11
30
0
26
70
37
100
Darwin
1
5
0
18
95
19
100
Darwin Rural
4
40
0
6
60
10
100
East Arnhem
3
27
0
8
73
11
100
Goldfields
1
50
0
1
50
2
100
Katherine
3
16
0
16
84
19
100
Kimberley
0
0
1
100
1
100
Nganampa
1
14
0
6
86
7
100
Queensland
0
0
1
100
1
100
Unknown
0
0
5
100
5
100
Subtotal
35
25
1
1
105
74
141
100
Western Diagnostics Pathology Service
Alice Springs
1
100
0
0
1
100
Alice Springs Remote
4
20
0
16
80
20
100
Darwin
2
10
0
19
90
21
100
Darwin Rural
4
12
0
29
89
33
100
East Arnhem
2
10
0
18
90
20
100
Katherine
1
10
0
9
90
10
100
Perth
0
0
1
100
1
100
Subtotal
14
13
0
92
87
106
100
Total
52
20
1
0.4
208
80
261
100

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The 27.4% (95% CI, 18%–40%) and 20.3% (95% CI, 16%–26%) resistance found in isolates reported in this study in 2007 and 2008 are comparable to the 22.7% (95% CI, 21%–25%) resistance found in isolates in Australia reported in the Australian Group on Antimicrobial Resistance survey in 2005 (Table 15).8 No detectable increase in resistance to azithromycin in the S. pneumoniae bacteria was found.

Table 15: Comparison of azithromycin resistance (resistant and intermediate) to invasive and non-invasive Streptococcus pneumoniae isolates collected from Aboriginal people (number resistant/total tested), 2005 to 2008, by state or territory

State or territory
AGAR monitoring NTSRU monitoring
2005 2007 2008
% Number resistant/total tested % Number resistant/total tested % Number resistant/total tested
New South Wales/ACT
27.8
162/583
NR
NR
Northern Territory
NR
23.4
11/47
20.9
48/230
Queensland
28.2
80/284
NR
0
0/1
South Australia
20.9
82/392
40.0
6/15
20.0
4/20
Victoria
14.5
35/221
NR
NR
Western Australia
16.2
48/296
NR
20.0
1/5
Unknown
0
0
0
0/5
Australia
22.7
404/1,776
27.4
17/62
20.3
53/261
(95%CI)
21,25
18,40
16,26

AGAR Australian Group on Antimicrobial Resistance.

NR Not reported.

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Discussion

Surveillance data presented to the NTSRU clearly indicate that trachoma is still endemic in Australia.

In 2008, 235 of the 287 (82%) communities in the Northern Territory, South Australia and Western Australia were categorised as being At Risk for trachoma in 16 regions. A similar proportion of communities were screened in 2008 (51%) compared with 2006 (57%) and 2007 (52%). However, Western Australia showed a significant increase (P < 0.05) in community coverage, 64% in 2006 and 88% in 2008, and Northern Territory showed a significant decrease (P < 0.05) in community coverage, 78% in 2006 and 49% in 2008. The community coverage in South Australia has been consistently lower than the other jurisdictions; there was no significant difference between the community coverage in 2006 (24%) and 2008 (15%). A trachoma workshop organised for April 2009 discussed ways in which screening can be implemented to maximise the number of communities screened and the number of children examined in South Australia.

The decrease in community coverage in the Northern Territory was in part due to the non-inclusion of communities examined during the AGEI. Data collected by the AGEI have been presented with caution in government reports due to limited training of staff collecting the data. For this reason they have not been presented in this report. The HSAK program, which provided data for other Northern Territory communities, did not re-visit communities screened by the AGEI.

In the years 2006 to 2008 there has been much discussion regarding the best way to report screening coverage of children. The NTSRU has explored the reporting of ABS regional population data of resident children, ABS population data for children resident in Communities At Risk, and the estimated number of children in communities where screening was conducted as provided by health care workers in the communities. Community statements of the children resident in each community vary compared with the ABS data, in part due to the high mobility of Aboriginal people. The ABS population data for children resident in Communities At Risk of trachoma was used to enumerate the children in communities where screening should have been conducted but was not. For example, in South Australia, the majority of communities have not been screened so it is not known whether they have trachoma or not; by including the number of children in these communities there will be a better understanding of the number of children who are not being examined. There were increases and decreases in the regional screening coverage, although the overall coverage for each jurisdiction was similar across the three years. Less than half of the children residing in Communities At Risk are being examined, emphasising that there are still many gaps in the screening.

In each jurisdiction there are regions with endemic trachoma. Across all the jurisdictions the average prevalence of active trachoma in communities from which data were reported, was 21% compared with the 14% reported for 2007 (P < 0.05) but there are no consistent changes in regional prevalence. Caution must be exercised due to variable coverage and small numbers. The majority of communities, 53 (69%) of the 77 where comparisons could be made, showed no change. Overall, a decrease (P < 0.05) in prevalence was found in South Australia (15% in 2006 and 2% in 2008) and Western Australia (24% in 2006 and 15% in 2008), and an increase (P < 0.05) was found in the Northern Territory (13% in 2006 and 29% in 2008). Reports of no active trachoma within some South Australia ACCHS should also be taken with caution because in many of these regions only very small numbers of children were examined.

Screening all children and providing azithromycin treatment as appropriate to household and community members is a necessary component of trachoma control. The surveillance data indicate that household and community treatment has improved from 2006 to 2008 according to the CDNA guidelines and possibly due to the operation of the NTSRU. Treatment was reported to have been distributed according to the CDNA guidelines in 35 communities (85%) in the Northern Territory and 41 (79%) in Western Australia; most of the regions within these jurisdictions treated more than 80% of the people who required treatment. However, South Australia has consistently examined few children at the schools and continues to treat children found to have active trachoma without providing household or community treatment. Family members can cause a cycle of ongoing re-infection. The issue of re-infection is something that has been considered by CDNA that proposes cross-regional and cross-state treatment where people are known to move frequently across borders because of strong family/cultural links.3 Western Australia has implemented this coordinated approach to treatment distributing azithromycin to most people who required treatment.

Poor facial hygiene is an important risk factor for trachoma and the promotion of facial cleanliness is a key component of the SAFE strategy. This has improved in 2008, with many communities reporting the promotion of facial cleanliness through the use of programs and resources to integrate behavioural change regarding hygiene.

The reporting of trichiasis data has improved, although still only 4% of those At Risk were examined. In 2007, only Western Australia reported the systematic screening for trichiasis. In 2008, almost every region reported data on trichiasis screening although in many regions this was still incomplete. The inclusion of trichiasis screening into existing programs such as the Adult Health Check and influenza vaccination programs has made it possible to assess the later stages of trachoma. This should lead to appropriate referrals for surgery when trichiasis is identified.

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Improvements have been made for the reporting of the Surgery, Antibiotics and Facial Cleanliness activities of the SAFE trachoma control strategy, however these components still need to be strengthened. In 2008, 57% of communities reported having an existing referral process for trichiasis surgery for adults (Table 4), a marked increase compared to the 4% that reported this information in 2007.2 In 2008, three quarters (74%) of the communities distributed antibiotics to children with active trachoma, but not necessarily as needed to their household and community contacts (Table 4). It is apparent that activities for the Environmental Improvement component of the SAFE strategy have either not been comprehensively implemented or reported. However, there have been reports of the installation of new swimming pools in some of the remote Aboriginal communities. While research has shown considerable health and social benefits of the pools, efforts should also be made to improve housing sanitation, nutrition, education and access to health care.9

While the reporting of treatment has improved from 2006 to 2008, no change in antibiotic resistance of S. pneumoniae has been detected over this time. It was not possible to make comparisons for Western Australia as PathWest pathology service was not able to provide the NTSRU with antibiotic resistance data in either year due to difficulties in obtaining the necessary clearances.

The trachoma surveillance process has enabled key representatives involved in trachoma programs from each jurisdiction to share successes and ideas relating to trachoma screening and management. A cross-regional 'health blitz' focusing on outreach screening and treatment of multiple conditions has been discussed by some jurisdictions. This will assist with the collection of data from communities that share borders while also aiming to deal with the cycle of re-infection caused by population mobility.

Future control activities in all jurisdictions would benefit from incorporating simple health messages such as keep your face clean as part of existing programs aimed at children and families. Future activities should also consider the responsibilities of members of the screening teams. For example, an efficient team might include at least 2 people responsible for the examination of trachoma, a nurse to administer treatment, and a health worker to assist in engaging with the community. It is important for all health workers and organisations involved in the monitoring of trachoma to be accountable and to take responsibility for their roles.

In summary, jurisdictions have attempted to collate data from both state based and independent data collection authorities where trachoma is still thought to be present. There are still gaps and limitations in the reporting of data, however considerable improvements have been made over the last 3 years. Recommendations for the future include reviewing assumptions that Aboriginal children in urban communities are Not At Risk, screening all Communities At Risk, examining at least all children aged 5 to 9 years in these communities, whether they are attending school or not, and strengthening the implementation of trachoma control activities. Additional effort is required to ensure that azithromycin is appropriately distributed, facial cleanliness is actively promoted and that adults with trichiasis are detected and operated on. An increase in community and screening coverage will enable more stable and reliable estimates of the prevalence and distribution of trachoma, and strengthening the implementation of all four components of the WHO SAFE strategy will lead to the elimination of blinding endemic trachoma.

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Acknowledgements

Data collection

The organisations that collected and/or reported data were:

Northern Territory

Aboriginal Community Controlled Health Services staff

Australian Government Emergency Intervention

Centre for Disease Control, Northern Territory Department of Health and Families, Northern Territory

Healthy School Age Kids program: Top End and Central Australia

South Australia

Aboriginal Health Council of South Australia, Eye Health and Chronic Disease Specialist Support Program

Country Health South Australia

Ceduna/Koonibba Health Service

Nganampa Health Council

Oak Valley (Maralinga Tjarutja) Health Service

Pika Wiya Health Service

Tullawon Health Service

Umoona Tjutagku Health Service

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Western Australia

Aboriginal Community Controlled Health Services staff

Communicable Diseases Control Directorate, Western Australian Department of Health

Goldfields Population Health Unit

Kimberley Population Health Unit

Midwest Population Health Unit

Pilbara regions Population Health Unit

Antibiotic resistance

Institute of Medical Veterinary Science

Northern Territory Government Pathology Service

Western Diagnostics Pathology Service

National Trachoma Surveillance Reference Group

The NTSRU is advised by the National Trachoma Surveillance Reference Group, members of which include representatives from the following organisations:

Centre for Disease Control, Alice Springs, Northern Territory Department of Health and Families

Centre for Disease Control, Darwin, Northern Territory Department of Health and Families

Communicable Diseases Control Directorate, Western Australian Department of Health

Country Health South Australia

Eye Health and Chronic Disease Specialist Support Program, Aboriginal Health Council of South Australia

Kimberley Population Health Unit, Western Australia

National Aboriginal Community Controlled Health Organisation

Office for Aboriginal and Torres Strait Islander Health, Australian Government Department of Health and Ageing

Surveillance Policy and Systems Section, Office of Health Protection, Australian Government Department of Health and Ageing

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Author details

Betty Tellis1

Kathy Fotis1

Professor Jill E Keeffe1,2

Professor Hugh R Taylor2,3

1. Centre for Eye Research Australia, Department of Ophthalmology, University of Melbourne

2. Vision Cooperative Research Centre

3. Harold Mitchell Professor of Indigenous Eye Health, Melbourne School of Population Health, University of Melbourne

Corresponding author: Ms Betty Tellis, Centre for Eye Research Australia, University of Melbourne, 32 Gisborne Street, EAST MELBOURNE VIC 3002. Telephone: +61 3 9929 8704. Facsimile: +61 3 9662 3859. Email: btellis AT unimelb.edu.au

Abbreviations

ABS Australian Bureau of Statistics

ACCHS Aboriginal Community Controlled Health Service(s)

AGEI Australian Government Emergency Intervention

AHCSA Aboriginal Health Council of South Australia

CDNA Communicable Diseases Network Australia

CI confidence interval

EH&CDSSP Eye Health and Chronic Disease Specialist Support Program

HSAK Healthy School Age Kids program

IMVS Institute of Medical Veterinary Science

NR not reported

NTGPS Northern Territory Government Pathology Service

NTSRU National Trachoma Surveillance and Reporting Unit

SAFE Surgery, Antibiotics, Facial cleanliness, and Environmental improvement

TF Trachomatous inflammation – follicular

TI Trachomatous inflammation – intense

TT Trachomatous trichiasis

WDPS Western Diagnostics Pathology Service

WHO World Health Organization

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References

1. Tellis B, Keeffe JE, Taylor HR. Surveillance report for active trachoma, 2006: National Trachoma Surveillance and Reporting Unit. Commun Dis Intell 2007;31(4):366–374.

2. Tellis B, Keeffe JE, Taylor HR. Trachoma surveillance annual report, 2007: A report by the National Trachoma Surveillance and Reporting Unit. Commun Dis Intell 2008;32(4):388–399.

3. Communicable Diseases Network Australia. Guidelines for the Public Health Management of Trachoma in Australia. Canberra: Commonwealth of Australia; 2006.

4. Tellis B, Fotis K, Dunn R, Keeffe JE, Taylor HR. Trachoma Surveillance Report 2008: National Trachoma Surveillance and Reporting Unit: Centre for Eye Research Australia. 2009. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-oatsih-pubs-trachreport

5. Thylefors B, Dawson CR, Jones BR, West SK, Taylor HR. A simple system for the assessment of trachoma and its complications. Bull World Health Organ 1987;65(4):477–483.

6. Australian Bureau of Statistics. 2006 Census of Population and Housing. CatNo20680 2006.

7. Australian Bureau of Statistics. Australian Indigenous Geographical Classification Maps and Census Profiles, 2001; 2002.

8. Gotlieb T, Collignon P, Robson J, Pearson J, Bell J. Streptococcus pneumoniae Survey: 2005 Antimicrobial Susceptibility Report. The Australian Group on Antimicrobial Resistance: August 2006. Available from: http://antimicrobial-resistance.com

9. Hunter EM, Ellis RG, Campbell D, Fagan PS. The health of Indigenous peoples. Med J Aust 1992;156(8):575–577.

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This issue - Vol 33 No 3, September 2009