Examining a child for trachoma in the community
The Gobal Trachoma Mapping Project in Malawi

Trachoma in Malawi: from mapping to action plan

Dr Khumbo Kalua, Trachoma Technical Advisor for the Malawi Ministry of Health, reports on progress towards elimination of trachoma in Malawi, a densely populated country in southern Africa with 16 million inhabitants.

Using the opportunity provided by the Global Trachoma Mapping Project (GTMP) the Malawi Ministry of Health decided to map 25 districts suspected of being trachoma-endemic.

The mapping survey aimed to:

  • Determine the prevalence of active trachoma (TF) in 1-9 year-old children, and the prevalence of trachomatous trichiasis (TT) in adults aged 15 years and above

  • Guide the implementation of a trachoma program in any trachoma evaluation unit (EU) found to have prevalences of TF or TT higher than the elimination threshold set by the WHO.

WHO trachoma elimination targets - TF < 5% in children aged 1-9 and TT < 0.1%

Key features of the survey

  • Mapping carried out between 2013 and 2015, using the standard GTMP protocols
  • Total population in suspected trachoma endemic districts = 9 million
  • Number of evaluation units (EUs) = 28. In trachoma mapping, the population is divided into EUs first. It is helpful but not always possible for the EU boundaries to correspond with the boundaries of existing administrative divisions. Several Malawi districts had to be divided into multiple EUs as they were too large (they had populations of >250,000 people)
  • Sample size in each EU = 1019 children aged 1-9 years, inflated by 1.2 to account for non-response
  • 30 clusters of 30 households in each EU were needed to achieve the required sample size
  • In total there were 840 clusters and 25 200 households
  • GTMP-certified graders examined approximately 84 000 residents aged 1 year and over.

Mapping was carried out by 10 survey teams, each consisting of a GTMP-certified grader, a GTMP-certified recorder and a driver. Each team examined 1 cluster per day. Teams were assisted by a community health worker in each cluster and 3 senior staff provided supervision.

Survey results

Trachoma was identified as being a public health problem in 6 districts in Malawi. All 6 had prevalences of TF and TT above the WHO-defined elimination targets. None of the districts were providing trichiasis surgery services at the time of the survey.

The mapping also provided data on access to water and sanitation in each EU.

Table. Trachoma endemic districts in Malawi identified by the GTMP

District TF prevalence in children age 1-9 years (%) TT prevalence in 15+ year olds (%)
Mangochi 8.2 3
Machinga 7.2 4
Mchinji 21.3 3
Kasungu 13.5 6
Salima 17.1 9
Nkhotakota 11.1 3

Trachoma Action Plan

Based on the evidence provided by the mapping, a taskforce was formed involving all the key trachoma elimination stakeholders.

Trachoma elimination stakeholders in Malawi

In 2014, the taskforce drew up a 5 year trachoma action plan (TAP) to implement the SAFE strategy to eliminate trachoma in the 6 endemic districts.

Mass drug administration with azithromycin was started. Mangochi and Machinga districts, which had TF prevalences of 5.0–9.9%, were allocated one round of treatment. The remaining 4 districts were allocated three rounds of annual treatment. Interventions to address facial cleanliness and hygiene improvements (F&E) were begun.

The TAP also planned how to increase productivity of Malawi’s trichiasis surgery services by strengthening infrastructure, human resources and community involvement.

Improvements to infrastructure:

  • Procurement of trichiasis surgery instrument sets (3 per surgeon) and supplies
  • Renovation of eye theatres in district hospitals and purchase of theatre beds.

Increased human resources and community involvement:

  • Training and certification of 17 Ophthalmic Clinical Officers as trichiasis surgeons
  • Training ophthalmologists as district supervisors
  • Training 100 case finders per district to find and refer cases for trichiasis surgery.

Supporting and implementing partners were identified and the Ministry of Health took on the overall co-ordination of the programme. Standardised reporting and monitoring tools were put in place and stronger links developed with district hospitals.

The Queen Elizabeth Diamond Jubilee Trust agreed to finance the entire Malawi budget over the 5 years 2014-2019 through a coalition of partners active in the country.

Path to elimination

There is now an active trachoma elimination programme in Malawi. 1500 people with trichiasis have already been operated on and the Ministry of Health believes that the TT elimination goal will be reached by 2018, ahead of schedule.

The last planned mass drug administration will take place in October 2016. After this, a round of impact surveys will measure the prevalence of TF and a surveillance period will begin in districts that are found to have a TF prevalence of less than 5%.

In addition, stakeholders are working to jointly implement water, sanitation and hygiene (WASH) interventions in areas identified by the survey. These should have an impact on trachoma and other diseases of public health importance and improve the general quality of life for many people in Malawi.

The trachoma mapping exercise has been crucial in helping to spur the Malawi trachoma elimination programme to its current productive state. There is justified optimism Malawi will achieve trachoma elimination well before the 2020 deadline.

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